Fiscal year 2024 grant

• $475,402

Fiscal year 2025 grant

• $484,013

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 2025 accomplishments

• The Diabetes Education and Prevention Program Team continues to build strong relationships with the ACHD and Adams County government, which allows them to develop multiple quality improvement projects that integrate different programs. Some of these projects included updating the program's website to be ADA-compliant, making it more accessible, as well as partnering with the data team to build out new self-registration portals, making it easier for people to register for programs.
• The team welcomed a new Community Health Worker who will provide the Heart Healthy Program and help facilitate the NDPP program.
• The team participated in over 29 outreach events this year, including attending local farmers' markets, health fairs, and other community-held events. These events help connect people across Adams County with their NDPP and DSMES programs.
• The team participated in the Community Clinical Linkages Program hosted by the Colorado Health Institute, a CCPD grantee, which allowed them to expand their network of support.
   

Fiscal year 2024 grant

• $106,000

Fiscal year 2025 grant

• $106,000

Geographic areas served

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

Communities served

• Rural populations, older adults, men, Medicare Diabetes Prevention Program (DPP) 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, resulting in an average of $2,800 savings per quarter.
• 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 2025 accomplishments

• Chaffee County continues to provide A1C testing to potential participants, along with follow-up A1C testing to existing participants. The Chaffee County Team has seen A1C testing as a powerful tool for both recruitment and retention, since individuals can see their A1C in real time and see it drop as they implement changes recommended by the program. Pre- and post-testing can help prove eligibility for the program, and show participants tangible changes to their health. A1c test results sent to their providers also provide value and build program credibility.
• Chaffee County hosts two DPP alumni groups, one in the city of Buena Vista and one in  the city of Salida, on a bi-monthly basis. The average weight loss is 6.4% in Buena Vista and 7.8% in Salida.
• Chaffee County strongly encourages its participants to utilize a tracker to better understand their habits, including food, activity, and anything else they may find helpful. Participants use either a paper tracker or an online tracker. Lifestyle Coaches review food diaries weekly to provide feedback. Of the many DPP testimonials, one participant noted, “I have lost over 30lbs in the 16 weeks of Core classes and now the ongoing Alumni classes. AND, my A1c dropped from 6.4 to 5.1! How did I do this? Coming to class! And learning to read labels, meal planning, and food tracking. Thank you, thank you.”

Fiscal year 2024 grant

• $680,000

Fiscal year 2025 grant

• $800,000

Geographic areas served

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

Communities served

•  Denver residents, with an enhanced focus on divested communities, including vulnerable ages, persons with disabilities, and People of Color (Black, American Indian or Alaska Native, Asian, Hispanic/Latinx, Native Hawaiian or other Pacific Islander, Middle Eastern/North African/Arab, Multi-Racial populations, and other identities not
  listed).

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 2025 accomplishments

• CALC hosted a May Quarterly Coalition meeting that drew more than 50 attendees, making it the largest CALC meeting since the pandemic began in 2020. Community Connectors sent personal invitations to the coalition meeting, which had a focus on updates to the Micro-Grant Program. The Micro-Grants Program supports grassroots projects that encourage active transportation and make Denver’s streets safer, more vibrant, and more connected.
• CALC has increased the integration of Community Connectors into Denver Department of Transportation and Infrastructure (DOTI) project teams, which has been a good tactic for boosting DOTI’s reputation in the community by leveraging the talents and relationships Community Connectors have, and for creating more opportunities for engagement for Community Connectors.
• CALC participated in 102 events and directly engaged with 6,961 people.
• The CALC Micro-grant program funded 150 projects with $196,698 by the end of 2024. Compared to 2023, the number of applications in 2024 increased by 52%, the number of projects funded increased by 34%, and engagement with Denver residents through Micro-grant projects more than doubled to an estimated total of 112,785 people, equal to 15% of Denver’s population.
  
   

Fiscal year 2024 grant

• $496,968

Fiscal year 2025 grant

• $700,000

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 2025 accomplishments

• The organizations in the network of clinical partners and community-based organizations successfully established ten referral pathways to National Diabetes Prevention Programs (NDPP), Diabetes Self-Management Education (DSME), and Self-Measured Blood Pressure Monitoring (SMBP) services.
• Clinical and Community-based organizations strengthened their relationships, reported a high level of trust and confidence in one another, and reported satisfaction with the network’s screening and referral workflow established in FY24.
• CHI developed a Best Practices Toolkit as a resource for organizations interested in developing and implementing community-clinical linkages to address chronic disease prevention and management in their communities.
   

Fiscal year 2024 grant

• $1,000,000

Fiscal year 2024 grant

Primary contact

• $1,000,000

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.

Fiscal year 2024 accomplishments

• Incorporated the 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 2025 accomplishments

• The CDC sent out a call for nominations to identify organizations/programs that use strategies to improve the implementation outcomes of lifestyle change interventions. Of the 100+ nominations received, INSPIRE-CVH was one of 18 programs selected to participate in the initial evaluability assessment (EA). The EA consisted of a two-day site visit resulting in a report that summarized overwhelmingly positive findings from the EA and brief recommendations on the feasibility of conducting future evaluations of CPC’s implementation improvement strategies.
• The CPC Program Manager conducted in-person site visits with each INSPIRE-CVH location. These visits gave CPC valuable insight into how the CHWs work and the communities in which they work, and how these factors affect their ability to impact their participants' lives.
• CHWs at INSPIRE-CVH sites completed 488 repeat health assessments on participants utilizing the LE8+-based health assessment. The CHWs bring participants back to complete repeat biometric and risk factor screens, demonstrating the benefits of the INSPIRE-CVH prevention program by showing improvements in the LE8+ health measures. 
   

Fiscal year 2024 grant

• $800,000

Fiscal year 2025 grant

• $800,000

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 2025 accomplishments

• Each jurisdiction successfully drafted a timeline and strategy to pursue seven identified PSE changes. Denver Department of Public Health and Environment (DDPHE) is focused on Healthy Food Retail, Neighborhood Urban Food Production, and Food Systems Funding. FJNWA is focused on Support Small Markets, and Vacant and Underutilized Land for Urban Agriculture. JCPH is focused on Advancing Coordination and Collaboration, and Land Access Priorities.
• FJNWA gathered with nearly 60 people at the ABC Community Hub for a Community-Led Planning Meeting hosted by the Grassroots Leadership Council (GLC). The GLC is a coalition of resident leaders and local organizations (including East Colfax Community Collective, Food Justice NW Aurora, Project Worthmore, Street Fraternity, and the Denver Justice Project). The purpose of this meeting was to open a discussion among people who live and work in northwest Aurora and present recommendations for the Colfax Community Vision and Action Plan, which the City of Aurora is developing in collaboration with the consulting group Progressive Urban Management Associates (P.U.M.A.) Five resident leaders presented on the impact of five challenges in the community, and five organizational leaders presented recommendations to address these issues: access to basic goods and services (which centers access to affordable, nutritious food), support for small businesses, housing conditions, housing affordability, and community safety.
• The JCPH FIC staff collaborated with the JCPH Communications team to design and launch a food insecurity awareness campaign during the holiday season. The campaign received nine media pickups, including one news broadcast in English (Fox31), two news broadcasts in Spanish (Univision and Telemundo), and a print article in English (Jeffco Transcript). These efforts had hundreds of viewers of these news broadcasts, reached 3,122 social media users, and drove 297 web visits, where viewers learned about Jefferson County's work and PSE change priorities.
• The  DDPHE FIC staff moved into a facilitator role for the Land Access working group of Denver’s Sustainable Food Policy Council. In partnership with this group, FIC staff provided technical assistance and leadership to bring community and government entities along in exploring the current zoning code and laying the groundwork to develop a community-driven Farmer-Friendly Zoning Vision. FIC staff also activated this group to begin advocacy for community agriculture and land access in major public redevelopment projects (the Park Hill Golf Course redevelopment). FIC staff are partnering with and providing technical assistance and funding for Denver’s Southwest Food Coalition to lead advocacy, engagement, and strategy to secure a sustainable source of funding for food justice efforts. 
   

Fiscal year 2024 grant

• $750,000

Fiscal year 2025 grant

• $750,000

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 2025 accomplishments

• Vuela implemented classes at the Peña Clinic within Denver Health, significantly improving access for Denver Health's Spanish-speaking patients. The turnout was strong, with 61 individuals enrolled across two classes at the Peña location, and 32 participants attending at least one class during FY25.
  The CDC selected the Corazon Sano team out of over 100 applicants to participate in an Evaluation Assessment to help the CDC identify novel strategies to improve implementation outcomes for lifestyle change interventions. The team met with the CDC for over two days to review their program structures and delivery strategies.
• Vuela provides SMBP, DSMES, and NDPP programs to Spanish-speaking individuals. During FY25, 191 participants attended one or more one-on-one SMBP sessions. 463 participants attended one or more sessions of NDPP, and 256 participants attended one or more sessions of DSMES.
   

Fiscal year 2024 grant

• $900,000

Fiscal year 2024 grant

• $900,000

Geographic areas served

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

Communities served

• People of color from diverse racial and ethnic backgrounds, semi-urban and rural communities, and communities affected by health inequities.

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 youth of color).
• 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 (similar to a community health worker) was invited to attend the American Public Health Association’s 2024 Policy
• Action Institute conference alongside the Adams County Health Department’s (ACHD) project lead. KIND has expressed interest in leading this work and developing more advocacy skills to help them spearhead policy change.

Fiscal year 2025 accomplishments

• The City of Louisville in Boulder County celebrated the passage of its Healthy Drinks in Kids Meals (HDKM) ordinance on Sept.17, 2024. This policy requires restaurants in Louisville that offer a bundled kids' meal to make the default beverage either water or an unflavored milk/non-dairy alternative. The policy was implemented on April 1, 2025, and impacts approximately 4,190 children ages 0-14 in Louisville.
  ACHD and the Healthy Sips, Healthy Kids Coalition built support for a Healthy Drinks in Kids Meal ordinance in Commerce City. They achieved success in engaging with 35 local restaurants through outreach conducted by promotoras, with a handful of restaurants expressing interest in voluntarily updating their kids’ menus.
• Pueblo Department of Public Health and Environment (PDPHE) and the Drink To Grow Pueblo Coalition built support for their HDKM campaign by presenting to organizations in their community. They successfully secured endorsements from the Early Childhood Council, Colorado BlueSky, Pueblo District 70, and the Children’s Hospital of Colorado. PDPHE presented the HDKM to the Pueblo City Council in May to increase education and awareness of this initiative and determine the city council's support for it.
• Garfield County Public Health educated its community about the harms of sugary beverages at a training in April for school nurses, community health workers, dental providers, parents, and community members. The event featured speakers on HBC4A’s efforts, targeted marketing, and the parallels between tobacco and sugary beverage industry tactics. They gathered contact information for interested individuals to support their HDKMl initiative in Carbondale.
• The Public Health Institute at Denver Health (PHIDH) conducted outreach and education with over 2,800 restaurants in Denver through in-person and newsletter efforts, in partnership with Vive Wellness and the Colorado Restaurant Association. They provided education about the Denver Healthy Drinks in Kids Meal policy, which took effect on July 1, 2025. They also partnered with the Denver Department of Public Health and Environment to create a webpage that provides information on the ordinance and a form for restaurants to request technical assistance.
  Arapahoe County Public Health, Boulder County Public Health, Jefferson County Public Health, and the Public Health Institute at Denver Health all worked to explore community interest for sugary beverage taxes. Together, they engaged over 100 community organizations, 25 community leaders, and 25 city council members throughout FY25.

Fiscal year 2024 grant

• $180,858

Fiscal year 2025 grant

• $178,258

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 2025 accomplishments

• KCCDPHE partnered with the Prairie Family Center, a trusted community organization, to implement a Digital Health Literacy Program. The Prairie Center provides one-on-one and group coaching to help individuals answer all their questions about digital health literacy. These individual and group sessions are designed to help individuals become more comfortable with technology and telehealth, which can help increase access to services in rural communities, including programs offered by KCCDPHE.
• The Kit Carson team established two days to visit Flagler, Colorado, for DSMES visits, which helps reduce transportation barriers for participants.
• The Kit Carson team partnered with the Colorado State University Extension Office to provide a smoothie workshop, that taught participants how to add more fruits and vegetables to their diet. This workshop was a huge success with participants.
   

Fiscal year 2024 grant

• $232,097

Fiscal year 2024 grant

• 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, 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 2025 accomplishments

• Metro Caring served 73 participants in their DSMS program and started two support groups for program completers. Classes were held in English, Spanish, and Arabic.
• The Arabic-speaking classes were the fastest-growing cohort. This cohort accepts participants who do not necessarily qualify for the program based on their health status. These participants are often interested because their family and loved ones have diabetes, and report that the information they learn is invaluable.
• Metro Caring started using blood sugar testing for active and potential participants, which was very successful in providing concrete health information and supporting participant recruitment and retention.
   

Fiscal year 2024 grant

• $150,000

Fiscal year 2025 grant

• $150,000

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 2025 accomplishments

• NCHD completed its first NDPP cohort in Logan County. 100% of participants completed the program, which received glowing reviews. Due to numerous barriers in Logan County, including limited public transportation, inadequate cell and internet infrastructure, and a lack of healthy food options, this is a significant success. Furthermore, the word-of-mouth from participants will help attract future participants.
• NCHD initiated three additional cohorts during FY25, including two in Logan County and one in Washington County. This increased the program from one cohort in 2024 to three cohorts in 2025. This is a significant accomplishment, given the smaller population size and multiple barriers to access.
• NCHD also updated its NDPP supplier status to include a distance learning component, which allows it to reach more participants who may live in remote parts of the counties it serves, and also enables participants from different counties to participate, thereby reducing overall barriers to access. 
   

Fiscal year 2024 grant

• $1,030,000

Fiscal year 2025 grant

• $1,030,000

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 2025 accomplishments

• AsthmaCOMP, in collaboration with the Colorado Department of Education school health team and other school nurse leaders, developed the Colorado Asthma Friendly School Survey. This award recognizes schools that meet standard asthma best practices with two required activities (completion of the school nurse asthma foundation course and a system to identify students with asthma), and four additional categories that include delivery of health services, provision of asthma education, healthy school environment, and managing physical education and activity. Schools that meet the minimum criteria demonstrate a commitment to providing the basic components of a school-based asthma program. Of the 20 schools invited to pilot the program, 11 met the criteria; five at the Gold (highest level) and six at the Bronze (basic level).
• School Nurse Education Program
  • This initiative has trained over 350 school and community-based nurses. The AsthmaCOMP Program Manager co-led asthma-specific modules in Fort Morgan, Grand Junction, and Fort Carson, ensuring best practices reach communities statewide.
• National Leadership
  • The AsthmaCOMP Program Director shared insights on school-based asthma management through the American Academy of Allergy, Asthma, and Immunology (AAAAI) podcast. At the AAAAI Annual Meeting, the AsthmaCOMP Program Manager was named incoming co-chair of the School-based Asthma Management Program, where she will help shape national strategies for school-based asthma and anaphylaxis care.

Fiscal year 2024 grant

• $385,983

Geographic areas served

• Statewide.

Communities served

• Public health practitioners, state agencies, local public health departments, and clinicians who 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

Fiscal year 2025 grant

• $990,000

Geographic areas served

• Clinic system sites are located in 32 out of 64 Colorado counties (patients from neighboring counties also served), and clinic system sites are 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 reach of EBIs.
• More than 16,231 patients were screened for colorectal cancer and 37 patients were diagnosed in FY24.

Fiscal year 2025 accomplishments

• Clinic systems gained momentum with their EBIs, such as full integration into their workflows and additional testing. Despite capacity challenges, nearly all participating clinics increased their colorectal cancer screening rates between 2023 and 2024.
• Clinics participated in an end-of-year Learning Collaborative to share their progress and lessons learned. This was a wonderful opportunity for clinics to learn from each other and find ways to collaborate.
• CCSP received an American Cancer Society partner of the year award. This award explicitly notes CCSP's work in promoting equitable access to screening, especially in rural and underserved communities, and the measurable difference it has made in the lives of Coloradans.
• As part of the effort to reduce health inequities, several clinic systems translated client reminders and patient educational materials into Spanish to reach Hispanic and Spanish-speaking populations, who have lower colorectal cancer screening rates than non-Hispanic white and Black populations. 
   

Fiscal year 2024 grant

• $450,000

Fiscal year 2025 grant

• $450,000

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 2025 accomplishments

• Expanding patient reach and home support
  • JKB enrolled 124 patients and completed 234 home visits, marking a significant increase from previous years.
• JKB launched an interactive indoor activities map, publicly available via QR code, that highlights safe places for families on high-pollution days. This dynamic tool, alongside education packets and in-person teaching, equips families with practical ways to reduce exposure to indoor/outdoor pollutants while staying active and engaged.
• Direct impact on patients and families
  • Facing financial hardship, language barriers, and frequent ER visits, one family received wraparound navigation support. JKB connected them to food, housing, and utility assistance and provided culturally tailored education. The child’s asthma is now better controlled, and the parent said, “I finally understand it because someone finally explained it to me.” Another family struggled with adherence due to language barriers and a recent diagnosis. JKB provided a Spanish-language Asthma Action Plan, improved medication adherence to 90% , and even supported a caregiver in quitting smoking.

Fiscal year 2024 grant

• $199,354

Fiscal year 2025 grant

• $165,000

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 and the Center for Improving Value in Health Care (CIVHC) collaborated on an evaluation. CIVHC used data from the Colorado All Payer Claims Database 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, the National Navigation Roundtable, and the White House efforts on Cancer Navigation.

Fiscal year 2025 accomplishments

• LRPC, in partnership with the Alliance, held four webinars to educate 331 stakeholders on reimbursement topics for CHWs/HNs.
• The April Alliance two-day meeting gathered over 100 people in person and nearly 75 online to discuss the sustainability of CHW work in Colorado. LRPC hosted two calls with Medicaid, two calls with stakeholders engaged in Medicaid/Medicare billing, and two meetings with managed care networks and experts to build the Alliance agenda to provide the current codes, processes, policy updates, and strategies for implementation.  The meeting also gave rise to four working groups that will continue into the next fiscal year to foster routine, ongoing convenings.
• Utilizing the Colorado All Payer Claims Database, CIVHC and LRPC partnered to evaluate the expansion of community health workers across Colorado. The final report had positive results overall. On average, patients with access to CHWs had total health care cost savings of $10,832.16 per member per year, compared to those without CHWs (p<0.01). Overall, patients of clinics with CHW access tended to have significantly lower (p<0.01) average total health care costs ($10,832.16), inpatient hospitalizations (28.3%), and emergency department visits (10.8%).

Fiscal year 2024 grant

• $250,882

Fiscal year 2025 grant

• $250,882

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 2025 accomplishments

• SLV LFC worked as the Colorado Department of Agriculture Community Food Access grant and tax credit outreach and technical assistance provider for San Luis Valley and Huerfano counties. The team brought nearly $800,000 to the region to increase access to healthy,  fresh, and local foods in USDA-designated low-income, low-access communities. A number of grocers in the region have been able to upgrade or buy new equipment that has increased the amount of food they can carry. This work has been essential to do in concert with the action planning because it provided a tangible example to food producers and retailers of the value of working with the LFC, and helps retain food access in communities that could easily lose their only grocery stores.
• SLV LFC facilitated 13 focus groups and 18 action planning sessions, with 307 attendees, to gather input on policy, systems, and environmental change goals across the SLV.
• SLV LFC added 15 new project stewards to its coalition roster through community engagement. 
   

Fiscal year 2024 grant

• $254,567

Fiscal year 2024 grant

• $271,180

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.

Fiscal year 2025 accomplishments

• YMCA exceeded enrollment targets for both DPP and SMBP. The enrollment coordinator helped reach potential participants and sign them up for the programs.
• The YMCA continued to build its Spanish-speaking NDPP program, and 39% of enrollment came from Spanish classes. They also welcomed an additional bilingual lifestyle coach to their team.
• NDPP coaches noticed an increase in stress and uncertainty in many participants' lives. They also noticed that classes provided social support for some participants, as they connected with one another more often. These interactions ranged from finding a buddy to walk with to inviting others over to all meal prep together.