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Spotlight on Innovation: 21st Century Care

As the recipient of a $19.8 million federal Health Care Innovation Challenge grant, Denver Health is increasing service integration, expanding services, improving quality of care, and reducing costs through their 21st Century Care model. Denver Health and partner Mental Health Center of Denver began implementing the model after receiving their three-year grant from the Center for Medicare and Medicaid Innovation Center in July 2012. The model transforms the primary care delivery system by providing enhanced services focused on each individual’s medical, behavioral, and social needs. Anticipated outcomes of 21st Century Care include cost savings, increased quality and scope of care, and workforce training.

The model builds on Denver Health’s patient-centered medical homes and has two distinct approaches; one for lower risk patients and one for higher risk patients. All patients receive access to a health information technology portal that provides access to their provider, monitoring, prompting, and referrals and engages patients in their own care. “For our low-risk patients, providing them with electronic support in the form of appointment reminders and health promotion messaging reduces no-show rates and helps keep them on track to stay healthy,” explained Tracy Johnson, PhD, Director of Health Care Reform Initiatives at Denver Health. “Our higher risk patients with more health problems often need more frequent and/or involved face-to-face visits and these individuals are supported by a variety of new care team members – patient navigators, behavioral health consultants, nurse care coordinators, and clinical pharmacists – who work with the traditional care team to closely monitor patient health status, develop interdisciplinary care plans, and support patient self-care between visits.”  

In addition to these approaches for both high and low risk patients in their regular primary care clinics, Denver Health has also opened three new high-risk clinics:  an intensive outpatient clinic (IOC) for adults with a history of avoidable hospitalizations, another adult clinic based at the Mental Health Center of Denver for individuals with severe mental health diagnoses and avoidable utilization, and a clinic focused on children with special care needs. These clinics focus on serving patients with a history of, or are at risk for, avoidable hospitalization and are staffed by multidisciplinary clinical teams adapted to the specific needs of the target population.

Over the three year period, Denver Health estimates the program will save over $40.4 million including $12.8 million in federal savings, $3.9 million in state savings to Medicaid, and $23.7 million that will be reinvested in providing services through 21st Century Care. Partners also anticipate being able to serve an additional patients 15,000 patients, most of whom are low-income and have Medicaid or are uninsured or underinsured. Denver Health has hired, trained, and placed 23 navigators, two clinical pharmacists, five behavioral health consultants, three pediatric nurse care coordinators, and multidisciplinary staff for three new high risk teams.  Denver Health is also investing more than $8 million in its IT infrastructure to support the effort.

“It’s exciting to be able to develop and implement an innovative model of care that builds on our  patient-centered medical homes and anticipates a future in which our health care system is less tied to fee-for-service payment and siloed efforts that often fail those patients most in need,” said Dr. Johnson. “Our hope is that 21st Century Care will become a model for implementing patient center medical homes adapted to the risk profile of patients.” The CMS Innovation Center awarded several Health Care Innovation Center grants to Colorado organizations in 2012, and is currently reviewing a new round of applications to be announced later this year.

For more information on 21st Century Care, contact Paul Melinkovich, MD, Principal Investigator at, or Tracy Johnson, PhD, Co-Principal Investigator at