Ambulatory Health Promotion

Office of Value Based Performance

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The Ambulatory Health Promotion (AHP) is a population health management collaboration between University of Colorado Health and University Physicians, Inc. The purpose of AHP is to enhance the delivery of preventive and chronic disease services by providing proactive outreach to select University of Colorado Health (UCH) patients to help them be up-to-date with preventive care guidelines. We currently have the following established outreach programs: 

• Preventive Services:   Yearly outreach to adult patients overdue for guideline-based recommended services, including, as appropriate per patient age and sex,  health maintenance visits, laboratory tests and immunizations, screenings for breast cancer, cervical cancer, colorectal cancer, and osteoporosis.
• Diabetes:  Monthly outreach to adult diabetic patients not currently meeting recommended diabetes care goals.
• Transition of Care: Daily review and phone outreach to adult patients recently discharged home from an UCHealth hospital or outside facility (hospital, SNF, or rehab) after an inpatient stay. This occurs within 2 business days of discharge, and includes triage and coordinating patient follow-up with the PCP clinic care team.  Daily review to send letter or My Health Connection outreach to adult patients, meeting criteria, who have been seen in an UCHealth Emergency Department.
• Hypertension: Weekly outreach to adult patients who are part of the hypertension registry with an average systolic blood pressure of ≥150 who need a primary care visit for hypertension management.  Quarterly outreach to adult patients who are part of the hypertension registry with an average systolic blood pressure of 140-149 who need a primary care visit for hypertension management.
• Fracture Liaison Service:  Weekly outreach to patients discharged from an UCHealth facility with diagnoses of fragility fractures that indicate osteoporosis. AHP facilitates the scheduling of bone density screening, lab work as needed, primary care follow-up visit, and care coordination with the primary care clinical pharmacy team.  
• PCP Letter Outreach:  Bi-monthly outreach to patients aged 65 and older who meet certain risk criteria and have not been seen in their PCP clinic in greater than 11 months
• Elevated PHQ9:   Weekly outreach to patients with an elevated depression screening score within the last 4-6 weeks who do not currently have follow up scheduled with their primary care provider or a mental health provider.
• Aspirin for Secondary Prevention:  Contact Sarah Billups, PharmD for protocol specifics:  Identify patients with an indication for aspirin for secondary prevention but no documented use.  Collaborate with provider and contact patient to either initiate aspirin, or correct documentation to indicate use or contraindication.  Work is facilitated by pharmacy interns.