CCPD funding portfolio

Diabetes Self-Management Education and Support (DSMES)

• Participants completed an average of 3.5 hours of programming, achieving improvements in medication adherence, weight loss, and psychosocial confidence.
• Significant clinical improvements included reductions in HbA1c levels and improved disease management.
• One grantee provided wraparound services to 75 participants, such as food pantry access and cooking classes. All reported improved dietary choices and cultural inclusivity.

National Diabetes Prevention Program (NDPP)

• 1,203 participants enrolled across 17 counties, including seven rural counties.
• 65% of participants met risk-reduction goals such as increased physical activity and weight loss, surpassing national averages.
• Participants reduced body weight by 5.9% and increased weekly physical activity by 439% (37.07 minutes pre- to 199.87 minutes post-intervention).
   

Self-Monitored Blood Pressure (SMBP)

• Participants in CCPD-funded SMBP programs achieved an average reduction of 11.33 mmHg in systolic blood pressure (an 8.5% improvement) and 5.27 mmHg in diastolic blood pressure (a 6.4% improvement).
• Blood pressure control rates increased to 93.8%, with 36% achieving AHA-recommended levels (<120/80 mmHg).
   

Home-Based Asthma Management

• 162 home visits were provided to 101 participants enrolled across 6 counties, in which healthcare navigators identified potential environmental asthma triggers in the home, provided training on medication usage, and coordinated resources to reduce the impact of environmental triggers.
• Participants reported improved inhaler use techniques and reduced symptom severity, as evidenced by a significant increase in average Inhaler Device Assessment (IDAT) scores (3.81 to 4.52) among participants.
• Programs connected families to resources addressing asthma triggers, contributing to better symptom control, as evidenced by a significant increase in average Pediatric Asthma Control and Communication Instrument (PACCI) scores (3.25 to 3.75) among participants.
• This project aims to enhance participants' continuity of care by meeting them at clinic appointments and fostering a seamless connection between clinic education and home-based support.

School-based Asthma Management

• In the 20 schools piloting the program, 101 participants enrolled, achieving a 98% retention rate in FY24.
• Asthma control scores improved from 21.5 to 23.0, inhaler proficiency rose from 17% to 93%, and emergency visits decreased from 24% to 8%.
• 67% of caregivers reported significant asthma improvements in students, with 91% achieving their health goals.
   

• Grantees passed 4 municipal-level policies and 5 organizational-level policies, which resulted in standardizing all Denver school zones, creating Slow Zones in pedestrian-generating spaces, removing sugary drink options from kids' menus in Denver, and meeting policies focusing on purchasing local food and beverages and eliminating sugar-sweetened beverages. 
• Initiatives included increasing active spaces and enhancing decision-maker engagement through community events and surveys.
   

Colorectal Cancer Screening

• Increased screening rates from 27% in 2022 to 36% in 2024 among 65,012 eligible patients across 16 safety net clinics.
  Implemented evidence-based interventions (EBIs) in 94% of clinics, including over 4,000 client reminders and 25,000 provider reminders in January through June of 2024.
• 88% of clinic representatives surveyed felt their clinic's capacity had improved in implementing an EBI to increase colorectal cancer screening rates.
• Recognized nationally for leadership in colorectal cancer prevention, with program outcomes presented at state and national forums.

Cardiovascular Health Innovation

• Enrolled 1,357 participants in programs addressing cardiovascular health, with a 63% completion rate.
• Reported 61% of participants improved cardiovascular health scores and 50% reduced cardiovascular risk scores through targeted health strategies.
• Collaborative efforts with community health workers and local organizations enhanced program reach and participant engagement, addressing disparities in cardiovascular and behavioral health outcomes.
• This project aims to build and strengthen relationships and coordination among community and clinical organizations to improve chronic disease prevention and management among people living in the metro area.
   

• As part of a successful pilot, the program established key partnerships between two clinics and three community organizations and supported partnering sites in adopting an innovative workflow adaptation to incorporate patient-centered screening and referral systems for chronic disease prevention and management. 
• Three (3) community events enabled the grantee to identify barriers to chronic disease prevention, maximize resource utilization, foster community awareness, and help sites connect with the communities. 95% of attendees reported learning about effective strategies and resources to manage chronic diseases.
• The grantee developed a key best practices tool kit for establishing and maintaining effective community-clinical linkages (CCL), which can be shared with partners.    
   

Fiscal year 2024 grant

• $475,402

Primary contact

• Michelle Harris
  • Email: mharris@adcogov.org

Geographic areas served

• Adams County; Adams-Arapahoe border communities of Aurora, Byers, Bennett, Strasburg, and Watkins; Adams-Denver border communities.

Communities served

• Adults over 65, Black and African Americans, Hispanics, monolingual Spanish speakers, low-income and uninsured persons.
• Adams County Health Department (ACHD) aims to increase the number of service locations in its programming and the number of community members who have access to and complete the Diabetes Self-Management Education and Support (DSMES) and National Diabetes Prevention Program (NDPP) services.

Fiscal year 2024 accomplishments

• ACHD increased its reach to its monolingual Spanish-speaking population. It established contracts with Clinica Colorado and Clinica Family Health regarding program referrals and co-location space. It had its largest Spanish-language NDPP cohort, which began in April 2024 with 11 eligible participants.
• DSMES participants who self-selected Spanish as their preferred language rose from 15% of total participants served in fiscal year 2023 to 50% in fiscal year 2024.
• Maintained historical community-based organization partnerships, while building new relationships, including a contract with the Center for African American Health around co-location and co-facilitation of DSMES classes and program promotion.
• Partnered with the Adams County Health Department Communications Team to update program flyers and webpages, as well as design and implement the social media and communications plan, and produce video for NDPP promotion.
   

Fiscal year 2024 grant

• $106,000

Primary contact

• Rebecca Rice
  • Email: mailto:rrice@chaffeecounty.org

Geographic areas served

• Chaffee County and some of Saguache, Park, and Lake counties.

Communities served

• Rural populations, older adults, men, Medicare Diabetes Prevention Program beneficiaries, and those with low socioeconomic status.

The program at Chaffee County Public Health (CCPH) aims to reduce cardiovascular disease and related factors while promoting health equity and helping to reduce health disparities by focusing on priority populations that are disproportionately burdened by chronic disease.

Fiscal year 2024 accomplishments

• Chaffee County Prevention Program averages 80 free blood sugar (HA1c) tests with health navigation per quarter, which significantly increases potential participant enrollment and readiness. A self-pay HA1c test averages $35, so that’s an average of $2,800/quarter savings.
• CCPH has enhanced its health equity focus through the addition of the Chaffee Community Clinic, a free mobile health clinic, to connect with people with significant physical and mental health needs - many of whom are experiencing housing insecurity, poverty, and lack of transportation.
• CCPH maintains and strengthens local health care provider partnerships with this representative testimonial from one M.D.: “There was a tipping point during the Virta study recruitment when I consistently noticed my patients in DPP were lowering A1c’s, losing weight, reducing medications, and sharing that it’s been life-changing for them. So I no longer just suggest DPP to at-risk patients. Now I strongly recommend DPP to them and make sure they have your (CCPHs) contact info and that I send their contact info in your referral form. And I tell them that my other patients comment that the DPP is life-changing.”

Fiscal year 2024 grant

• $680,000

Primary contact

• Shaylee Zaugg
  • Email: shaylee.zaugg@denvergov.org

Geographic areas served

• Denver, with an enhanced focus on Department of Transportation and Infrastructure Equity Areas (priority neighborhoods).

Communities served

• Denver residents, with an enhanced focus on divested communities (e.g., vulnerable ages, persons with disabilities, BIPOC communities).

Denver Community Active Living Coalition (CALC) aims to make active living and healthy choices the default by promoting community-driven action, connecting communities to available resources, providing culturally appropriate education and capacity-building programs, improving policies and systems, and increasing access to safe, convenient, and fun places for walking, rolling, biking, taking transit, and participating in active play and recreation in the City & County of Denver.

Fiscal year 2024 accomplishments

• Micro-Grant Funding Boosts Relationships

  • Micro-Grants have become a core CALC program for building new and existing relationships and establishing trust. One hundred fourteen individuals and organizations were funded in fiscal year 2024, and 87 micro-grantees “strongly agree” that their micro-grant allowed them to make a positive impact in their community that they wouldn’t have made otherwise.

• Walking, Biking, and Rolling Groups Both Educate and Enhance Engagement

  • Community conversation facilitated while actively moving together is a powerful advocacy tool; this method has ultimately led to the successful awarding of a $800k+ Crime Prevention through Safer Streets grant for the East Colfax neighborhood.

• Pathways to Partnerships

  • CALC participated in 89 events, directly engaged with 7,345 people, and reached 1,905 people through social media posts, newsletters, and blogs. For one project, they connected government agencies, a nonprofit organization, community members, and youth to transform a dilapidated basketball court and overgrown trail. The project created a pathway to partnership and community trust and turned a neglected space into a safer, beautified space where the community can be more active.
     

Fiscal year 2024 grant

• $496,968

Primary contact

• Lauren Bell   
  • Email: BellL@coloradohealthinstitute.org

Geographic areas served

• Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, and Jefferson counties.

Communities served

• People with diabetes, heart disease, and related risk factors such as prediabetes, high blood pressure, high cholesterol, and food insecurity.

This project aims to build and strengthen relationships and coordination among community and clinical organizations to improve chronic disease prevention and management among people living in the metro area.

Fiscal year 2024 accomplishments

• Developed a screening and referral workflow to establish best practices for connecting people to evidence-based programs and food and nutrition-related resources to address chronic disease prevention and management.
• Developed a Partner Referral Guide containing key partner referral information and main points of contact for sites to assist clinics and community-based organizations in coordinating referrals through regular project site feedback, and 1-on-1 connections.
• The Colorado Health Institute, along with community engagement partners, created community engagement events that matched the interests and needs of community members in the Westwood neighborhood, southwest Denver, and northeast Denver. The events proved to be very successful, with 176 adults and children participating in the events, which included knowledge sharing about the prevalence of chronic disease, available community programs and resources to support, and interactive Zumba fitness dance classes. More than 70% of participants identified Spanish as their primary language. Bilingual staff and resource table hosts throughout the event aided in the success and involvement of all participants.
   

Fiscal year 2024 grant

• $1,000,000

Primary contact

• Nick Flattery
  • Email: nick.flattery@cpcmed.org

Geographic areas served

• Chaffee, Costilla, Route, Moffatt, Denver, Adams, Alamosa, Conejos, and Garfield counties.

Communities served

• Underserved rural and Latino populations.

INSPIRE-CVH is a series of innovations aimed at increasing the quality, impact, and efficiency of a Community Health Worker/Health Navigator-led public health program that concurrently addresses cardiovascular and behavioral health to reduce health disparities.

• Incorporated American Heart Association’s Life’s Essential 8 components into the INSPIRE-CVH participant health assessment and aligned evidence-based recommendations for each of the 8 categories.
• INSPIRE-CVH developed two stress intervention handouts and trained the Community Health Workers (CHWs) on the best practices for disseminating the tools.
• INSPIRE-CVH prioritized rural and frontier communities that see more health disparities in Colorado, with CHW partners in Garfield, Conejos, Denver, and Chaffee counties and support for participants at High Plains Community Health Center and Vuela for Health.
• CHWs and Promotoras performed health coaching activities with over 2,500 community participants in FY24.
   

Fiscal year 2024 grant

• $800,000

Primary contact

• Paola Babb
  • Email: paola.babb@denvergov.org

Geographic areas served

• City and County of Denver, Jefferson County, and the City of Aurora.

Communities served

• Community residents, including people with low incomes, children and youth, and people of color from diverse racial and ethnic backgrounds.

This project aims to increase the number or percentage of Coloradans living in FIC jurisdictions consuming healthy foods and beverages by making healthy foods and beverages more affordable and readily available.

Fiscal year 2024 accomplishments

• The creation of three community-facing reports following six community listening sessions for Policy, Systems, and Environmental (PSE) change prioritization. These reports include findings from a land use policy assessment, GIS analysis, PSE change prioritization outcomes from the community listening sessions, and next steps. The format and presentation of these reports vary, reflecting the unique characteristics and stages of food systems PSE change work in each jurisdiction.
• Food Justice Northwest Aurora successfully coordinated a community meeting, in collaboration with Councilmember Crystal Murillo, to address grocery access in northwest Aurora following Walmart's announced closure. They engaged with city officials, property owners, and other stakeholders to discuss the impact and potential strategies to support small markets and improve grocery access.
• The FIC teams were honored for their impactful work, with the Jefferson County Public Health Food Policy and Systems team receiving the Public Service Award from GoFarm for their efforts in advancing health equity and building a resilient local food system. Additionally, Paola Babb from the Denver FIC team was recognized as a food justice leader at the Denver Food Rescue’s 10th-anniversary gala, celebrating her contributions to the Denver community’s well-being and resilience.
   

Fiscal year 2024 grant

• $750,000

Primary contact

• Rocio Pereira
  • Email: rocio.pereira@dhha.org

Geographic areas served

• Adams, Arapahoe, Broomfield, Denver, Jefferson, Pueblo, and Weld counties.

Communities served

• Spanish-speaking adults; underserved community members who have low rates of insurance, no established primary care, low income, and low education.

The Vuela Corazon Sano (Vuela ‘Healthy Heart’) project aims to expand access to culturally and linguistically appropriate National Diabetes Prevention Program (NDPP), Diabetes Self-Management Education (DSME), and Self-Measured Blood Pressure Monitoring (SMBP) services.

Fiscal year 2024 accomplishments

• Expanded Access to Services: Denver Health and Hospital Authority (DHHA) and Vuela continued their partnership and have worked to make the referral process easier, allowing better access to programming through Vuela.
• The Vuela team delivered NDPP to 760 participants with 417 of those participants attending more than one class. Additionally, Vuela enrolled 353 participants into their DSME program and 164 participants into their SMBP program.
• Vuela aims for NDPP participants to increase their intake of culturally appropriate healthy foods, which they achieve through education and cooking classes. Of the 350 participants surveyed, 258 (74%) reported increasing the number of vegetables they consume, and 127 (27%) of them increased the number of fruits they ate.

Fiscal year 2024 grant

• $900,000

Primary contact

• Andrea Pascual
  • Email: andrea.pascual@dhha.org

Geographic areas served

• Adams, Arapahoe, Boulder, Denver, Garfield, Jefferson, and Pueblo counties.

Communities served

• BIPOC populations, semi-urban and rural communities, populations suffering from economic coercion, political disenfranchisement, and racial oppression.

This project aims to address health inequities in communities by creating a culture that rejects the targeted marketing and the excessive availability of sugary drinks in Colorado’s food system through support of municipal-level sugary drink reduction policies that will reduce the prevalence of chronic diseases.

Fiscal year 2024 accomplishments

• On March 27, 2024, the City and County of Denver adopted a policy for municipal healthy drinks in kids’ meals. The policy will be implemented on July 1, 2025. The policy will impact 713,252 Denver residents (113,121 children 0-14, of which about 65% are BIPOC youth).
• Pueblo Food Project and ViVe Wellness developed organizational policies for healthy meetings and events, with a focus on purchasing local food and beverages and eliminating sugar-sweetened beverages.
• To advance this policy, systems, and environmental change work, community voice needs to be central to the policy process. As the experts in their communities, community members and community-based organizations need to be leading the charge and advocating for change. In Adams County, Kids in Need of Dentistry’s (KIND) lead promotora was invited to attend the American Public Health Association’s 2024 Policy Action Institute conference alongside Adams County Health Department’s project lead. KIND has expressed interest in really leading this work and developing more advocacy skills will help them spearhead policy change.
   

Fiscal year 2024 grant

• $180,858

Primary contact

• Valerie Boyd
  • Email: valerie.boyd@kitcarsoncounty.org

Geographic areas served

• Kit Carson, Cheyenne, and Lincoln counties.

Communities served 

• Rural, frontier, Spanish as the primary language, and those needing additional support in health literacy.

Kit Carson County Department of Public Health and Environment (KCCDPHE) aims to sustain and expand regional capacity to fight chronic disease by providing high-quality programming in the National Diabetes Prevention Program (NDPP), Diabetes Self-Management Education and Support (DSMES), and Self-Measured Blood Pressure Monitoring (SMBP) and piloting a digital health literacy program to decrease barriers to telehealth services.

Fiscal year 2024 accomplishments

• KCCDPHE created content for a Digital Literacy program. This program will focus on providing information and skills for community members who need help using technology. KCCDPHE looks forward to piloting this program, which it hopes will increase the usage of its programming through telehealth.
• KCCDPHE hired its first bilingual NDPP coach at the end of FY24. This will expand Spanish-speaking community members’ access to NDPP classes.
• The DSMES Program served 110 participants, which is an increase in participants from prior years.

Fiscal year 2024 grant

• $232,097

Primary contact

• Lannea Hand
  • Email: lhand@metrocaring.org

Geographic areas served

• Denver metro area.

Communities served

• People living with diabetes, focusing on families living with food insecurity due to economic challenges and individuals from communities disproportionately impacted by diabetes, particularly BIPOC community members.

Metro Caring works to increase access to its community-based, peer-led Diabetes Self-Management Support (DSMS) programs, which are grounded in equity and inclusion and improve health outcomes. It also supports DSMS participant learning with Healthy Eating, Active Living (HEAL) activities that foster community gathering spaces.

Fiscal year 2024 accomplishments

• Metro Caring had 114 individuals who participated in the DSMS Program, including 81 participants with diabetes, 23 caregivers/loved ones, and 10 peer educators (almost all of whom have diabetes). Thirty-six participants with diabetes attended classes in Arabic, 25 participants attended classes in Spanish, and 20 participants attended sessions in English. Fifty-four participants (66%) completed the program (defined as attending four or more of the DSMS sessions).
• DSMS alumni/participants were also involved in Healthy Eating, and Active Living sessions, including cooking clubs with diabetes-friendly recipes and support, trauma-informed yoga, seated pilates, stretching, and stress management/breathing. Twenty-three people attended cooking clubs and 76 participated in physical activity opportunities.
• Access to nutritious food was a cornerstone of the program. Metro Caring provided groceries that participants self-selected through Fresh Food Market weekly vouchers and delivered groceries to certain participants experiencing transportation barriers. In total, participants with diabetes completed 117 shopping trips via the program voucher, making the Fresh Food Market accessible to 37 unique households. Additionally, 113 grocery deliveries were made to program participants, making food accessible to 35 unique households.
• The first of its kind in Colorado, Metro Caring’s DSMS in Arabic involved over 30 participants using a transcreated curriculum from Scripps’ Project Dulce Diabetes Among Friends. To recognize and celebrate the unique aspects of Arabic culture, adjustments were made to the food offerings. Instead of the typical 15-carb snacks, each class featured a spread of culturally relevant and healthy options.

Fiscal year 2024 grant

• $150,000

Primary contact

• Talya Honstead
  • Email: talyah@nchd.org

Geographic areas served

• Logan, Yuma, Morgan, Phillips, Sedgwick, and Washington counties.

Communities served

• Rural and low socioeconomic status.

The Northeast Colorado Health Department (NCHD) wants to help community members make better lifestyle choices that can help reduce stress and lower their risk for type 2 diabetes.

Fiscal year 2024 accomplishments

• NCHD was able to retain 100% of its participants through the first seven months of its first cohort.
• NCHD has attended four community events in Yuma County to build relationships and advertise for its second National Diabetes Prevention Program (NDPP) cohort.
• NCHD employees shadowed the NDPP at Melissa Memorial Hospital in Phillips County to better understand how to deliver NDPP in rural settings. They also expanded their NDPP offerings into Logan County by partnering with a subcontractor.

Fiscal year 2024 grant

• $1,030,000

Primary contact

• Stanley Szefler
  • Email: stanley.szefler@childrens.org

Geographic areas served

• Denver, Arapahoe, Adams, Delta, Mesa, El Paso, Logan, Moffat, Montezuma, Prowers, and Weld counties. 

Communities served

• Children with asthma, ages 5 to 12 years, in schools in underserved areas.

AsthmaCOMP aims to define and designate school-based asthma programs (SBAPs) in six school districts in the Denver metropolitan area, train and mentor at least eight new asthma navigators to establish designated SBAPs in four Colorado regions outside of Denver, and engage at least three new high priority school districts outside these regions to develop SBAPs in rural areas.

Fiscal year 2024 accomplishments

• Built a partnership with the Colorado Department of Education Nursing Services to define a school-based asthma program, and a professional learning community to support the implementation of asthma best practices.
• Developed a checklist to identify and designate “Colorado Asthma Friendly Schools.”
• Worked with 20 schools to help them become “Colorado Asthma Friendly Schools.”
• Mentored asthma navigators in four regions outside the Denver area.

Fiscal year 2024 grant

• $385,983

Primary contact

•  Jamie Studts
  • Email: jamie.studts@cuanschutz.edu

Geographic areas served

• Statewide.

Communities served

• Public health practitioners, state agencies, local public health departments, clinicians that screen for lung cancer.

The primary goals of the project were:

• Generate a comprehensive assessment of lung cancer screening and related factors in Colorado, including challenges, opportunities, and resources to inform efforts to expand equitable implementation of lung cancer screening across Colorado and reduce the devastating impact of lung cancer.
• Complete a Network Adequacy Assessment and map key existing partners who can be leveraged to advance lung cancer screening work in Colorado with lung cancer burden and eligible populations to assess priorities for focusing future efforts.

Fiscal year 2024 accomplishments

• The project team delivered a thorough evaluation of lung cancer screening in Colorado, focusing on the current access and distribution of lung cancer screening programs.
• The project team presented the results and actionable recommendations to the Colorado Department of Public Health and Environment for further consideration.

Fiscal year 2024 grant

• $990,000

Primary contact

• Andrea Dwyer
  • Email: andrea.dwyer@cuanschutz.edu

Geographic areas served

• Clinic system sites located in 32 out of 64 Colorado counties (patients from neighboring counties also served) and clinic system sites located in 18 out of 21 Health Statistics Regions.

Communities served

• Individuals served by safety net clinic systems eligible for colorectal cancer screening, including rural/frontier, communities of color, low-income, Medicaid/Medicare, and underinsured populations.

The Colorado Cancer Screening Program (CCSP) aims to increase colorectal cancer screening rates among safety net clinic systems across the state by implementing select evidence-based interventions (EBIs), reducing disparities.  These efforts create a strong statewide structure to increase preventive cancer screenings and access to care among medically underserved communities

Fiscal year 2024 accomplishments

• Sixteen out of 19 participating clinic systems developed and began implementing an EBI Action Plan focused on 1-2 EBIs (client reminders, provider reminder/recall systems, provider assessment and feedback, and standing orders).
• All participating clinic systems participated in quarterly Learning Collaboratives, monthly or quarterly 1:1 technical assistance meetings, and supplemental training webinars for technical assistance and peer sharing.
• Clinics established baseline colorectal cancer screening rates (average 5% increase between 2022 and 2023) and began tracking the reach of EBIs.
  More than 16,231 patients were screened for colorectal cancer and 37 patients were diagnosed in FY24.

Fiscal year 2024 grant

• $450,000

Primary contact

• Monica Federico
  • Email: Monica.Federico@childrenscolorado.org

Geographic areas served

• Adams, Arapahoe, Boulder, Broomfield, Denver, El Paso, Jefferson, and Weld counties.

Communities served

• Just Keep Breathing serves high-risk pediatric asthma patients ages 2 to 17.

The mission of Just Keep Breathing is to extend personalized asthma education into the home and practical life of the high-risk asthma population, aiming to address social determinants of health, achieve asthma control, and decrease hospital admissions and revisits in general.

Fiscal year 2024 accomplishments

• Enrolled 101 patients and conducted 162 home visits, where participants received standardized and tailored asthma management education.
  JKB worked with subject matter experts to create a standardized protocol for providing HEPA air purifiers to families living in areas with high levels of particulate matter pollution. This protocol also included a recreation and activity guide for children with asthma, containing information regarding recreation on high pollution alert days. These materials were reviewed to align with health literacy standards, translated into Spanish, and will continue to be adapted and improved as needed.
• This year, a family was recruited from an inpatient stay, where the patient showed a lack of understanding of medications and faced several barriers to care. Despite initial difficulty engaging this family, with the assistance of JKB, the patient has not been readmitted in several months.

Fiscal year 2024 grant

• $199,354

Primary contact

• Betsy Risendal
  • Email: betsy.risendal@cuanschutz.edu

Geographic areas served

• Statewide.

Communities served

• Underserved populations.

This project aims to achieve health policy changes to sustain Health Navigation services with public and private payers.

Fiscal year 2024 accomplishments

• To understand the impact of Community Health Workers (CHWs) on patient outcomes in Colorado's primary care settings, the Latino Research and Policy Center (LRPC) and the Center for Improving Value in Health Care (CIVHC) collaborated on an evaluation. CIVHC used data from the Colorado All Payer Claims Database (CO APCD) to analyze outcomes from patients of five health care system primary care clinics, comparing patients with access and without access to CHW services between 2018 and 2022.
• LRPC conducted interviews and listening sessions with six payer experts/health plan representatives, ten medical providers, 12 business and administration groups, and 24 CHWs and Health Navigators (HNs) to gather recommendations.
• Built on the partnership with Health Care Policy and Finance, and gained interest from national organizations such as the American Cancer Society Cancer Action Network (ACS CAN), the National Navigation Roundtable, and the White House efforts on Cancer Navigation.

Fiscal year 2024 grant

• $250,882

Primary contact

• Max Gibson
  • Email: max.slvlocalfoods@gmail.com

Geographic areas served

• San Luis Valley region; Alamosa, Conejos, Costilla, Mineral, Rio Grande, and Saguache counties.

Communities served

• Residents of the SLV, farms, ranches, food businesses, processors, and historically underserved populations.

The San Luis Valley Local Foods Coalition (LFC) is conducting food system action planning and implementation to increase access to healthy foods and market opportunities for small local producers across the six San Luis Valley counties.

Fiscal year 2024 accomplishments

• Since publishing the SLV Community Food & Agricultural Assessment (which had 184 summit attendees and 1,153 survey respondents), partners and the community have expressed considerable excitement about the work's next steps.
• Hosted a Policy System and Environmental (PSE) change training with 26 attendees and deepened the SLV team's understanding of PSE change work.
  SLV LFC has attended 26 events and engaged with 1,450 people throughout the San Luis Valley around healthy food access.

Fiscal year 2024 grant

• $254,567

Primary contact

• Jessica Giffin
• Email: jgiffin@denverymca.org

Geographic areas served

• Adams, Arapahoe, Denver, Douglas, El Paso, Jefferson, Pueblo, Teller, and Weld counties.

Communities served

• People with high blood pressure, at risk of developing diabetes, with a focus on Hispanic/Latino, Black/African American, men, and Medicare beneficiaries.

The YMCAs National Diabetes Prevention Program (NDPP) and Self-Measured Blood Pressure Monitoring Program (SMBP) aim to increase the number of individuals with prediabetes or hypertension who enroll, participate in, and complete these programs.

Fiscal year 2024 accomplishments

• The YMCA exceeded its enrollment goals, with 163 enrolled in DPP and 63 enrolled in SMBP. SMBP retention was 74% (attending at least 4 out of the 8 office hours), and DPP retention was recognized by Y-USA (the national organization of YMCA) as above average.
• YMCA has worked hard to create a robust referral network with their clinic partners and has active referral partnerships with many health systems including Denver Health, Swedish Family Medicine, Englewood Primary Care, Rocky Mountain Primary Care, Uptown Community Health Center, and Inner City Health. They are participating in a learning collaborative with Colorado Health Institute to better build community-clinical linkages across the Denver metro area.
• The YMCA continues to screen its participants for social determinants of health and has many heartfelt stories of connecting people to resources when they most need support. They have connected people to access primary care appointments, provided access to their Beyond Hunger food distribution program, and assisted families with signing their kids up for YMCA summer camps and other programming with scholarships.
• The YMCA established a formal partnership with the local organization Lifespan Local to screen and connect the Hispanic /Latino community to NDPP and SMBP.