Need: Rural healthcare networks in Colorado and Washington felt the urgency to help their communities improve population health with better care at lower cost.
Intervention: The Community Care Alliance was formed to serve rural patient populations by assisting their healthcare organizations in transforming their practices to succeed at value-based reimbursement.
Results: Member healthcare communities have seen an increased collaboration among independent providers, clinics, and local hospitals on community health initiatives, patient transfers, and appropriate access and education.
The move from volume- to value-based healthcare started a
dialogue among Colorado's Western Healthcare Alliance
(WHA) members. WHA is a network of 29 healthcare
organizations throughout Colorado and Utah that aims to
improve regional healthcare through combining resources.
They knew something had to change in order to improve
population health and assure cost-effectiveness of local
WHA launched the Community
Care Alliance (CCA) in 2015. Through services and
educational resources, CCA helps member healthcare
facilities increase their value-based delivery of care
and create medical homes for their patients.
With the goal to help members aggregate their rural
populations and gain experience in population health
management, the CCA created 2 ACOs: the Rocky Mountain
ACO and the San Juan ACO. With funds from the Centers for
Medicare and Medicaid
ACO Investment Model, CCA supported care coordination
activities, technology resources, practice
infrastructure, and provider engagement efforts for
The following healthcare facilities are represented on
the CCA board of directors, but there are over 27 members
of CCA representing over 50 practices:
By way of the Valley View
Hospital, the CCA was originally partially funded
2014-2016 FORHP Rural Health Network Development
grant. Matching funds were provided by WHA members
who elected to reinvest profits from Healthcare
Management, a WHA subsidiary. CCA has established a fee
structure for its hospital and practice participants in
order to continue the Alliance's work.
The CCA infrastructure offers
services to meet various needs of members and their
Clinically Integrated Network – A
contracting platform in which hospital providers engage
with insurance payors in value-based payment
initiatives. Participants must meet the requirements of
a value-based environment in order to receive
Care Coordination Training and
Facilitation – Assists local care
coordinators, medical providers, and care teams in
implementing care coordination and team-based care to
improve patient outcomes.
Virtual education sessions – CCA
facilitates virtual care coordinator trainings as well
as monthly networking and learning collaboratives to
instruct members on the elements of care coordination,
ACO requirements, quality improvement, and other
services available through CCA.
Data Analytics and Predictive Modeling
– A platform from which medical practices can pull
reports and analyze patient data. With the information,
providers can assess beneficiary needs and sets
improvement goals and strategies with specific targeted
Quality Improvement Monitoring and
Reporting – Offers performance improvement
initiatives and supports reporting on quality measures.
Helps to facilitate TCPI's data use and reporting for
Network Support – Leverages existing
relationships across the spectrum of services, helping
to build bridges between participating members to share
resources and ideas to better meet the needs of the
A total of 43 organizational members have received
educational, networking, and technical assistance by
being a part of CCA's ACOs. Both ACOs consistently score
above the national average for quality.
All CCA participants have seen an increase in the use
of care coordinator-related Medicare codes and
reimbursement for services.
Member healthcare communities have increased
collaboration among independent providers, clinics, and
local hospitals on community health initiatives, patient
transfers, and appropriate access education.
CCA has seen an increase in the level of team-based
care as a result of members accessing their data
Member hospitals are experiencing a decrease in
emergency room utilization. The ACOs are constantly
monitoring hospital readmissions and utilizing care
coordination efforts to educate patients on the
appropriate use of the ER.
Over 22,000 Medicare beneficiaries have been
introduced to care coordination, leading to a decrease in
emergency room visits, an increase in overall health, and
lower medical costs.
More recently, a group of local employers in a rural
community have collectively contracted with CCA to
improve the health of their self-funded health plan
covered lives population.
Read about another Western Healthcare Alliance
initiative, the Laboratory Services Network,
in RHIhub's Rural Health Models and Innovations.
CCA has overcome these difficulties while helping their
members try to improve population health in their local
Rural practices often have limited resources
preventing them from hiring care coordinators.
Integration of clinical data: There are currently 14
EMRs used by participants, complicating the integration
of clinical data and adding to the complexity of quality
Providing education and resources to rural,
geographically disparate communities: CCA created
numerous toolkits and creative educational opportunities
to ensure participants have the tools and skills
necessary to be successful.
The CCA recommends the following key principles:
Paint the global vision for those involved: Express
what you as a network are wanting to achieve, formulate
the options of how to accomplish those goals, and
articulate the perceived benefits for the patients and
community members being served. Repetition is key.
Let the medical community lead: Success is often
linked to provider engagement within networks; utilize a
medical champion to communicate a vision to providers and
secure their involvement. Network leaders must stress the
importance of clinician engagement to involved
Members must hold each other accountable: Success
cannot rely on the efforts of a few members; All members
must be involved. All members should actively engage in
care coordination, quality improvement and practice
"Don't throw effort after foolishness": Value-based
transformation is a moving target and networks and
members must be prepared to make corrections along the
way. The membership should work together to identify
areas of improvement and strategies to correct and
maintain forward progress.
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.