Helping Coloradans Thrive

America’s systems of care for underserved people, families, and communities are broken. The COVID-19 pandemic underscored the broad weaknesses in our health and social service systems and the vast disparities of illness and death related to race, income, and living environment. Yet, as shown in the attached diagrams, we pay enormous amounts of money when people are really sick or get in serious trouble. Investing in prevention and thriving would improve people’s lives and ultimately save money. We have a major opportunity to transform our broken systems for the benefit of all.

The Collaborative Community Response Initiative (CCRI) is designed to bridge the gap between fragmented sectors and programs to provide integrated services for underrepresented people. CCRI encourages inclusive collaboration at the community level so that individuals and families can progress from fractured health and social barriers to thriving lives, as in this story.  

CCRI is a person, family, and community-centered approach that integrates health (public, physical, behavioral, and oral), social/human services, and community leadership. This collaborative, community-based approach is designed to prevent and eliminate disparities through easy-to-access whole person wrap around supports designed with the members we serve to improve their well-being and encourage their thriving. Local leaders can shape their community’s collaboration to meet local needs, supported by a sustainable common infrastructure that enables integrated delivery of all programs for marginalized people (in personalized plans developed with the family). Sustainability comes from investing in prevention and thriving – and paying for it with a share of the savings from avoided future illness and social problems, as summarized in this link.

The Farley Center was just awarded a major grant by the Department of Public Health and the Environment (CDPHE) to support four diverse Colorado communities in developing detailed plans to implement the CCRI model in their localities.

The Nuts and Bolts

We should invest in a sustainable, common, human, and technical infrastructure that will reduce fragmentation and encourage local collaborative structures. As described in the linked story, we propose creating a “commons” system that empowers communities and local leaders, especially those from underrepresented groups, to develop their own collaborative organization partnered with public health departments, human service agencies, primary care, mental health, and community-based organizations. Full-time “Commons Companions” like Rita in the attached story will create and implement (with organizational partners) personalized individual and family plans (developed with the beneficiaries) that provide individualized packages of whole-person, wraparound clinical and social services. They will use an interoperable IT system that enables this cross-sector collaboration, data sharing, and metric tracking to support the full continuum of care for individuals and families. We have developed a master three-level organizational structure for the CCRI itself, consisting of a local community collaboration structure, a regional facilitative structure, and a state-level administrative and service structure (all with input from national experts).

Grant funds can be used to build and refine this shared statewide human and technical infrastructure until the sustainable model of relying on a share of downstream savings to provide the extra investment needed in prevention and thriving is proven, as described in this paper. CCRI provides Colorado with the opportunity to invest in a transformative way that should lead to greater savings in the future. A shared, common infrastructure will empower communities to take charge of their own wellness and thriving. It's time we progress from the band-aids of incremental reform; we have the power to build bridges across fragmented health and social services. Together, we can encourage community collaborations and help all Coloradans to flourish.

We are a coalition, steered by more than 30 state and national leaders, agency heads, community members, and academics who have been working together for the past three years to design this comprehensive, transformative model. Get in touch and see how you can advance this cause.