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Colorado Health Access Fund2017 Annual Evaluation Report

EXECUTIVE SUMMARY

2 THE COLORADO HEALTH ACCESS FUND

Dear Stakeholders,

The Denver Foundation is pleased to share the second annual evaluation report on the Colorado Health Access Fund. As a result of the community partnerships profiled in this report, 17,000 Coloradoans accessed direct behavioral health and/or substance use treatment in the Fund’s second year. This brings the total number of individuals reached by the Colorado Health Access Fund to almost 50,000 people across the state.

While increasing behavioral health treatment access is a key driver of the Fund, learning and evaluation are core values that power ongoing improvement. Based on what we have learned since the Fund launched at The Denver Foundation in 2015, we’ve made changes to how we approach grantmaking and partnerships. We funded fewer—but larger —grants to support expansion projects more holistically. We’ve also narrowed our focus to increase the sustainability of projects. Hiring and retaining providers, especially for rural communities and those serving special populations, is a real challenge, and we continue to talk with partners on how best to address this difficulty. One strategy we implemented in Year Two was to modify our application process by inviting organizations to demonstrate their community leadership. We also increased outreach to rural communities and those serving vulnerable populations.

The demand for behavioral health services continues to be largely unmet for those with the greatest barriers to care. These are uncertain times in health care, but there is good momentum across the state to address behavioral health. The Colorado Health Access Fund will continue to evolve as a partner to best support this progress.

Christine Márquez-Hudson President and CEO

2017 ANNUAL EVALUATION REPORT 3

EXECUTIVE SUMMARY The Colorado Health Access Fund (the Fund) is focused on bringing behavioral health services to those who have had the least access and face the highest barriers to care. In its second year, 36 grantees from across Colorado received $3.9 million from the Fund. Initiatives supported by the Fund range from a program that connects immigrants in detention with highly trained social workers to school-based substance use treatment for Denver teens.

The services supported by the Fund are timely. Coloradans need better access to behavioral health care. The state struggles with one of the nation’s highest suicide rates, and it posted a record number of drug overdose deaths in 2016. Coloradans with low incomes and those who identify as African-American, American Indian, or Hispanic are more likely to report they didn’t get needed mental health care. An estimated 67,000 Coloradans said in 2017 they needed substance use disorder treatment but did not receive it.i

OUR ANALYSISThe Denver Foundation retained the Colorado Health Institute (CHI) to conduct an annual evaluation of the Fund. This evaluation report examines the work of the Fund’s second year. It is based on data from evaluation reports submitted by 35 of the 36 grantees supported during the funding year spanning 2016-17.

The evaluation addresses questions in three tiers:

Improved Health for Coloradans with High Health Needs

Increased Access to Behavioral Health Care

Increase Number of Behavioral

Providers

Build Behavioral Health

FacilitiesTelepsychiatry

Expand/Maintain Clinic

CapacityPolicy

Change

Learnings From Evaluation

Figure 1. Colorado Health Access Fund Theory of Change

EXAMPLES OF INTERVENTIONS

Colorado Health Access Fund

Tier One: Grantee Contributions What progress have CHA Fund grantees made towards impacting behavioral health access to care in Colorado? To answer this question, CHI used a framework called RE-AIM+P.

To assess grantee progress, results in the full report are structured around six areas: Reach, Effectiveness, Adoption, Implementation, Maintenance, and Policy. Collectively, this model is referred to as RE-AIM+P. This executive summary contains key findings identified using RE-AIM+P. See CHI’s full evaluation report.

Tier Two: Fidelity to the Fund’s IntentTo what extent has the CHA Fund stayed true to its original intent? The Fund’s intent includes helping Coloradans with high health care needs by improving access to behavioral health. (See Figure 1.)

Tier Three: The Fund’s Contributions to Behavioral Health in ContextHow is behavioral health care access changing in Colorado? A set of indicators puts in context the Fund’s contribution to the improvement of behavioral health among those with high health needs.

i The source of the suicide and drug overdose data is the Colorado Department of Public Health and Environment (CDPHE). The source of the substance use data is CHI analysis of the 2017 Colorado Health Access Survey.

4 THE COLORADO HEALTH ACCESS FUND

Tier One: What progress have CHA Fund grantees made towards impacting behavioral health care access in Colorado?Key FindingsThe Fund’s grantees implemented effective programs that provided access to behavioral health services to almost 17,000 Coloradans. These programs successfully served people with high health care needs and barriers to care (See Figure 2). The Fund served fewer people than in its first year, when 32,000 Coloradans were reached. That change reflects the Fund’s evolving strategy. Several large one-year grants ended, and the Fund focused on supporting organizations that offered smaller, more specialized programs targeting communities facing major barriers to care, such as people in detention or the Native American community.

Grantees used a mix of approaches to expand access to behavioral health care. Examples include telehealth, in-person counseling, and integrating behavioral health care services into primary care environments to best serve their target populations. (See grantee story on Page 5).

Despite the Fund’s overall success, grantees faced a variety of challenges. First, grantees cited difficulty in recruiting, hiring, and retaining behavioral health staff

About the Colorado Health Institute The Colorado Health Institute is a trusted source of independent and objective health information, data and analysis for the state’s health care leaders. CHI is funded by the Caring for Colorado Foundation, Rose Community Foundation, The Colorado Trust, and the Colorado Health Foundation.

About the Colorado Health Access Fund The Colorado Health Access Fund is a field of interest fund of The Denver Foundation. Established in 2014 with an anonymous gift of $40 million, the Fund is dedicated to improving health outcomes for underserved Coloradans by increasing access to behavioral health services.

Figure 2. Which Populations Are Grantees Reaching? (Grantees Could Target More Than One)

0 10 20 30 40 50 60

People earning low incomes or experiencing unemployment

People of color

People who are un/underinsured

Children

Adolescents

People with limited English proficiency

People experiencing homelessness or housing insecurity

Seniors

People who are trauma-affected or justice-involved

Families

People living in rural/underserved regions of the state

People who are homebound/disabled

57%

51%

37%

37%

34%

29%

26%

17%

17%

14%

14%

11%

Percentage of Grantees

as the most common barriers to implementing their programs. Second, many programs depend on the Fund’s financial support, raising concerns about their sustainability after their grants end. Finally, grantees cited challenges related to local, state, and national policies — from a failed local ballot initiative that would have funded a behavioral health center to changes in federal immigration policies. Potential and upcoming changes in Medicaid policy were also a source of uncertainty for many grantees.

2017 ANNUAL EVALUATION REPORT 5

A GRANTEE STORY:

DENVER INDIAN HEALTH AND FAMILY SERVICES

At a new Denver court for child custody cases involving American Indian children, Shelly Solopow is there to meet families at one of the toughest chapters of their lives. Solopow is a Licensed Professional Counselor (LPC) and Certified Addiction Counselor (CAC II) with Denver Indian Health and Family Services (DIHFS).

With the support of the Colorado Health Access Fund, Solopow attends every session of the Denver and Adams County Indian Child Welfare Act (ICWA) courts. She talks to American Indian parents who are involved with the child welfare system and tells them about therapy, substance abuse treatment options, and other health services.

“The folks I see in front of me are almost always adults who were traumatized as children and didn’t get the help they needed. Places like DIHFS, they get that,” says Judge Donna Schmalberger with Denver’s ICWA court.

Like DIHFS, grantees of the Colorado Health Access Fund offer compelling stories of how they are using

Shelly Solopow (left), a Licensed Professional Counselor with the Denver Indian Health and Family Services, discusses a case with Donna Schmalberger, the judge at Denver’s Indian Child Welfare Act (ICWA) court. The Colorado Health Access Fund supports Denver Indian Health and Family Services’ behavioral health services for people involved with the court. BRIAN CLARK/CHI

Tier One Recommendations

The challenges grantees face also provide opportunities for the Fund to strengthen its grantmaking. CHI recommends that the Fund:

Staffing • Continue to work closely with grantees with staffing

challenges that may prevent them from meeting their goals.

• Direct CHI’s mid-Fund research to examine staffing challenges, including issues related to workforce shortages, geographic distribution, salary differentials, and alternative staffing approaches.

Sustainability• Continue to conduct risk assessments when making

grants; support programs that can foster local partnerships; invest in programs that can support themselves financially.

• Connect grantees to existing trainings that address diversifying funding sources, billing, and sustainability planning.

• Direct CHI to evaluate sustainable grantmaking approaches as part of its research.

Grantmaking Focus• Continue funding and supporting grantees that are

serving the highest-need populations, including many currently funded programs.

• Use CHI’s 2018 research to ensure that future grantmaking meets the Fund’s health equity goals by addressing the most pressing behavioral health needs in the state.

• Encourage evaluation techniques that capture the information necessary to monitor how the Fund is addressing its health equity goals.

Tier Two: To what extent has the Fund stayed true to its original intent?Key FindingsThe Fund set out to improve access to care and health outcomes for Coloradans with high health care

the Fund to expand behavioral health care to their communities. For the full account of DIHFS work, as well as profiles of other grantees, see the full report.

6 THE COLORADO HEALTH ACCESS FUND

needs. It intended to send 20 percent of the grants to programs serving rural Coloradans and to support programs that address four focus areas: education of patients and families, access to care, transitions in care, and innovative care delivery.

In this tier, CHI answered three evaluation questions and found that the Fund had mixed results in Year Two.

Guiding Question: To what extent does the Fund target efforts to improve access to needed services and health outcomes among Coloradans with high health care needs?

Answer: The Fund expanded access to behavioral health services by increasing both its financial investment and the number of grantees in Year Two. However, it reached fewer Coloradans than in the prior year.

Guiding Question: Are the funds equitably allocated among rural, urban, and suburban areas? Do grantees reflect the state’s geographic differences?

Answer: No. In Year One and Year Two combined, 17.8 percent of funds went to programs serving rural Colorado. This rate falls short of the Fund’s intended 20 percent rural grant funding level. More than three quarters of the Year Two grantees — 26 of 35 — are primarily serving clients in urban areas along Interstate 25. (See Map 1.)

Guiding Question: Does the collective work of grantees address each of the Fund’s four focus areas — education of patients and families, access to care, transitions in care, and innovation in delivery?

Answer: Yes. As in Year One, all grantees addressed at least one of the Fund’s focus areas. The percentage addressing transitions in care declined from 56 percent in Year One to 40 percent in Year Two, primarily due to the end of several grants that had focused on this area.

Tier Two RecommendationsAfter analysis of the Tier Two findings, CHI recommends that the Fund:

Rural Outreach and Recruitment Strategy• Continue to investigate barriers that prevented

organizations from applying for a grant or from submitting a successful proposal. Evaluate whether to revamp the application process based on those findings.

• Encourage grantees that serve geographically diverse populations to focus on rural Coloradans.

• Encourage past grantees to apply again, especially if they have a rural focus.

Clear Communication During Times of Change• Continue to encourage grantees to talk with Colorado

Health Access Fund staff if their programs face

Map 1. Colorado Health Access Fund Grantee Locations

Denver Metro Area

2017 ANNUAL EVALUATION REPORT 7

barriers to implementation. Fund staff can work with grantees to promote progress or assist with program adaptations that maintain the Fund’s mission.

• Consider investing in a grantee perception assessment to inform grantmaking and grant management processes in the future — from reporting requirements to site visits to grantee selection.

Monitor Program Ramp-Up Time• Monitor ramp-up periods and work closely with

grantees to ensure they are meeting program targets.

Increase Grantmaking in Focus Areas• Target future grants towards two focus areas:

transitions in care and education of patients and families.

Tier Three: How is behavioral health access changing in Colorado?Statewide, some 7.6 percent of all Coloradans indicate they could not get needed mental health care, according to the 2017 Colorado Health Access Survey (CHAS). Figure 3 displays groups that are more likely to forgo care, whether because of cost, insurance barriers, or other challenges.

A look at the current state of behavioral health care access indicates that the Fund is contributing directly to the areas and populations that need it most — from adolescents and older Coloradans facing behavioral health challenges to immigrants and refugees experiencing upheaval. See CHI’s full report for additional data on the behavioral health of Coloradans.

CONCLUSIONIn its second year, the Colorado Health Access Fund is supporting grantees that are providing crucial behavioral health services to 17,000 Coloradans. Grantees’ approaches are as diverse as the people they serve. There will be much more to learn from the programs and people addressing behavioral health needs with support from the Colorado Health Access Fund.

Still, grantees are working at a time of both policy and cultural change, and the coming year is likely to offer just as much upheaval. The Denver Foundation’s challenge will be to help grantees navigate these changes effectively to ensure that their vital work continues. With the Fund’s support, grantees will continue providing opportunities for better health to thousands more Coloradans.

Figure 3: Percentage of Coloradans Reporting that They Did Not Receive Needed Mental Health Care in the Past 12 Months, 2017

Source: 2017 Colorado Health Access Survey * Federal Poverty Level

HISPANIC

7.8%

UNINSURED

11.3%PRIVATELY INSURED

5.8%

INCOME BETWEEN 0-100% OF FPL*

14.3%INCOME OVER 400% OF FPL*

4.9%

BLACK OR AFRICAN AMERICAN (NON-HISPANIC)

8.9%MULTIRACIAL

9.2%

PUBLICLY INSURED

9.9%

WHITE (NON-HISPANIC) 7.4%AMERICAN INDIAN OR ALASKA NATIVE (NON-HISPANIC)

22.5%

RACE AND ETHNICITY

INSURANCE STATUS

INCOME

ALL COLORADANS

7.6%

The Denver Foundation

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Denver, CO 80206

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Colorado Health Institute

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Denver, CO 80203

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@CoHealthInst

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