CIVHC, The Mile High Health Alliance (MHHA), and other organizations are launching a pilot to support populations that have complex medical conditions and are high utilizers of the health care system, especially emergency departments (ED). Despite the availability of patient information from the health information exchange (HIE) through the Colorado Regional Health Information Organization (CORHIO), ED staff are not able to access the data they need to identify and fully support the high needs population. Additionally, ED providers lack standardized response protocols and have limited connections to help them connect patients to cross-sector community resources.

Enter the Orange Flag Project.

The idea behind the project is simple: implement a health care data “flag” on electronic health records for individuals who are high users of health services and not currently enrolled in a coordinated care plan to adequately manage their needs. MHHA and their collaborators hope this upstream innovation can provide the foundation for solutions to overcome the lack of a proactive, coordinated, multi-sector care framework and begin to reduce excessive ED and hospital use in the Denver metro area.

How it Works

CIVHC’s role in the project is to provide a list of high utilizers insured by Colorado Access from the Colorado All Payer Claims Database (CO APCD) to CORHIO. With approval from Johns Hopkins, CIVHC plans to use their Adjusted Clinical Groups (ACG) software to create the high utilizers list using a select number of ACGs as well as well as filters for Denver Metro zip codes, individuals over 18, and those who are members of Colorado Access. Once the list is received, CORHIO will apply an “Orange Flag” to records on the list, visible to provider groups.

All data will be transmitted through a secure portal, and CORHIO will incorporate the orange flag indicator into dashboards they create that share information with providers about their patients. The orange flag data will afford the collaborators a real-time look at statistics about the high needs population, providing insights into how to best introduce interventions to help support the population.

As the data portion of the pilot moves forward, MHHA is also leading efforts to evaluate and develop protocols of intervention. The pilot participants are not only reviewing current protocols but also looking at programs that are closely aligned with this work to avoid duplicative efforts. Some of these projects include the Hospital Transformation Program and work within the Regional Accountable Care Entities (RAEs).

Impact on Patients and Providers

MHHA, CIVHC, and other organizations in the pilot expect to substantially improve the health and wellbeing of the current high needs population who often do not receive the right care at the right place or at the right time. Additionally, they hope to use predictive information to identify a pattern of care associated with people with high needs and anticipate potential interventions that could be more effectively implemented and result in reducing multiple ED visits.

This project will have a positive impact on providers and the workforce shortage as well. Moral distress and provider burnout is a major concern within the health care space. By arming providers with additional tools, they can regain a sense of control and positive impact on the wellbeing of their patients. Multiple providers have expressed that they are troubled by seeing repeated ED visits by the same person, for the same reason. Without access to resources, often the only treatment they can provide is to stabilize and discharge rather than address the underlying social health needs.

While the pilot is in early stages, all participants are excited about how it has brought together multiple stakeholders to innovate in an area with tremendous need. It will also be a novel use of ACGs in population identification as well as a new data collaboration between the HIE and CO APCD in Colorado.