Denver Health and Hospital Authority is receiving a CMS Health Care Innovation Award to create an ambulatory care model that will provide individualized care for patients' medical, behavioral and social needs. This model will target low income children and adults with diverse health care needs. It will coordinate care and offer self-care support between visits, enabled by HIT and team-based patient navigators, and will integrate physical and behavioral health services in existing primary care settings and newly created high risk clinics. The program will reduce reliance on emergency room care and reduce avoidable hospitalizations by providing better access to outpatient and social services, better care management and self-management of care, and better coordination and utilization of existing services, as well as more individualized care for the patients' medical, behavioral and social needs.
