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Spotlight on Innovation: MCPN Bridges to Care Hot Spotting

Across Colorado and the US, roughly 20 percent of the population is responsible for 80 percent of the health care costs ( This disproportionate amount of spending on a few has led to what’s been coined “hot spotting” – care coordination programs targeting high-risk, chronic condition patients aimed at reducing unnecessary ER visits and hospital stays. As sub-recipient of a federal innovation grant through the Center for Medicare and Medicaid Innovation (CMMI), Metro Community Provider Network (MCPN) in Aurora, CO, has seen over $145,700 in estimated cost-savings and a 63 percent reduction in utilization of hospital and ED services through their hot spotting care management initiative.

MCPN’s project, Bridges to Care, is part of the national project, Sustainable High-Utilization Team Model, which was awarded to Rutgers Center for State Health Policy (RCSHP) in July 2012. A Federally Qualified Health Center (FQHC), MCPN is one of four clinical partners implementing the program.  The other three provider group sites are located California, Missouri, and Pennsylvania. The model is based off of the work of the Camden Coalition of Healthcare Providers in New Jersey, which is serving as the clinical expert assisting the sites with adopting hot spotting and care management strategies. RCSHP, along with the Center for Health Care Strategies, provides overall administration and oversight of the $14.3 million dollar award.

“When we received the award last summer, hot spotting was not a new concept to us,” explained MCPN President and CEO David Myers. “The CMMI funding allowed us to expand our targeted efforts beyond high hospital utilization Medicaid patients and those with venous thromboembolism (VTE).”  With Bridges to Care, MCPN is targeting the uninsured, Medicaid, Medicare, CHP and CICP patients with chronic conditions and aims to serve over 900 patients during the three year program. With the first year spent primarily on planning and program development, MCPN has so far served 200 patients with their eight-week post-discharge care management services.

The team-based program uses a multi-disciplinary team to empower patients to better manage their health. The process is triggered when a patient in the hospital meets the criteria and is enrolled in MCPN’s post-hospital support services through a community health worker. Within 24-48 hours after discharge, a Nurse Practitioner or a Physician Assistant visits the patient in the home to provide a clinical visit.  A clinical care coordinator (filled by a social worker) then follows up to conduct a home, environmental and a psycho-social assessment. This visit is critical to make sure the patient has the social support they need to fill their prescriptions, find stable housing options, obtain income support and fill other primary needs such as transportation.

Each patient receives a minimum of one visit per week for eight visits by one or more members of the care team. The model is flexible to allow the visits to be driven by patient need. MCPN found out early on having a behavioral health specialist as part of the team was critical to keeping patients at home and out of the hospital or ER. “Many of our patients have underlying behavioral health complications, such as depression, that exacerbate their health problems and lead to recurring hospitalizations and ER visits,” explained Myers. As an example, MCPN enrolled a diabetic patient in Bridges to Care who was continually going to the hospital for high blood sugar episodes. “Until our behavioral health specialist began addressing the patient’s depression that was causing the recurring cycle of binge eating, spiked blood sugar levels, and ER visits, the vicious cycle wasn’t likely to end.”

A psychology Nurse Practitioner is also a member of the team should someone in the program need more advance psych care including medications. Medical assistants often accompany team members to the home visits to help with blood draws, chart documentation, and other support tasks. In addition to the clinical team members, each patient is also assigned a health coach who helps patients self-manage their health condition and establish goals.

MCPN is working with several community partners including Together Colorado, Aurora Health Access and Aurora Mental Health to provide the social support and care needed. University of Colorado Hospital is the primary hospital partner in the initiative. MCPN utilizes data from University’s EPIC electronic medical record to tier patients into risk categories to determine who might be a good candidate for the program.

When the team began their work, they were surprised to find that their initial target group (patients in the top 1-3 percent of all utilization and spending) was not the ideal candidates for the program. These “top tier” patients are typically comfortable with using the hospital and ER as a regular source of care and not particularly ready or willing to change their behavior and begin self-managing their health. MCPN instead began to focus on the top 8-12 percent of patients and have seen a higher level of engagement and results. To determine readiness and prior to confirming eligibility, patients must demonstrate a certain level of “readiness” to change based on their responses to a patient activation survey tool.

MCPN includes patients in their data analysis six-months after they complete the eight-week program to effectively gauge changes in utilization behavior.  Of the over 200 patients that have been served, 13 patients have met the criteria to be included in the most recent data collection and evaluation process.  The 13 patients were either uninsured (1), or had Medicaid (2), Medicare (1), or CICP (9).

Results to date include a 45 percent reduction in Emergency Department (ED) visits, 57 percent reduction in hospital admissions, and 79 percent reduction in hospital stays. Based on the decrease in use of high-cost services, MCPN estimates $113,400 in cost savings for hospital stays, and $32,300 in savings from reducing ED costs.

Utilization of ED and Hospital Services Pre- and Post- Bridges to Care


Hospital Stay and ED Visit Costs Pre- and Post- Bridges to Care

For more information on MCPN, visit or contact David Myers, President and CEO, at, or John Reid, Vice President of Fund Development, at