Friends, The Colorado Health Institute marks its 10th anniversary in 2012. We celebrate this milestone not as a point of pride for our organization but as an acknowledgment of the vision of those who saw the need for CHI, dreamed of what it could be and set it on its course with the highest of standards. Without this steadfast commitment over the past 10 years, we would not be where we are today. CHI is a product of the Colorado community. And we are grateful. To mark this occasion, the team at CHI is proud to present, “Colorado: A Picture of Health.” For those of us who research, analyze and strategize about how to best deliver health care, it’s all too easy to forget that our policies and decisions impact our fellow Coloradans, all five million-plus of us. This tribute to our state’s health serves as a reminder of those we ultimately serve. While health is found everywhere, we’ve focused our lens on areas that are most meaningful to the policies and decisions we make on the local
and state level and that will affect our most vulnerable – including children, the elderly and our communities. Over the past 10 years, we have made significant strides in health and health policy in Colorado. This book documents that progress. Yet there’s much work still to do. From expanding access to health care to improving health outcomes to building the infrastructure to meet tomorrow’s needs, we have unprecedented opportunities and challenges. As we look to the next 10 years, the Colorado Health Institute will continue to inform health policy and advance health. We thank our funders, Caring for Colorado, The Colorado Health Foundation, The Colorado Trust and Rose Community Foundation. Onwards!
Michele Lueck, President and CEO, Colorado Health Institute
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Upasana Mohapatra, a third-year student at the University of Colorado College of Nursing, meets with a patient at the Sheridan Health Services clinic on the Fort Logan campus in Denver. // Photo by Brian Clark
Colorado: A Picture of Health
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Chapter 1 Health and Our Lives pp. 4-9
Chapter 4 Health and Our Caregivers pp. 30-39
Chapter 2 Health and Our Most Vulnerable pp. 10-21
Chapter 5 Health and Our Communities pp. 40-47
Chapter 3 Health and Our Seniors pp. 22-29
Chapter 6 Health and Our Innovation pp. 48-57
INTRODUCTION
There are more than five million pictures of health in Colorado. The Colorado Health Institute was created 10 years ago to help Colorado see its health care system more clearly. To mark our anniversary, CHI took to the road, crisscrossing the state and searching out pictures of health. We found great dedication but also great suffering, life and death, new ideas and old problems, communities coming together and individuals making a difference, personal resilience and collective impact. Much has been accomplished. Much remains to be done. These photos can help tell the story. They can help build understanding. They can help us work together to make Colorado a healthier place to live.
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Nurse-midwife Shauna Jones shows a newborn girl to Zoey Ditton and her cousin, Desirae Deherrera, both 4, and their grandmother, Pam Keeton, at Montrose Memorial Hospital. Zoey and her family were awaiting the birth of her little brother. // Photo by Brian Clark
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CHAPTER 1
Health and Our Lives Health touches every aspect of life in Colorado – government, business, education, community and family. Health care accounts for about a quarter of the state budget. It eats up an increasing percentage of personal budgets. And it can make the difference between a productive life and one hobbled by illness. Colorado has been a leader in providing health care, but the economic downturn of the past years has revealed gaps in that care and has stretched funding to the breaking point. Many are now working to create a system that better meets today’s needs and positions Colorado for a healthier tomorrow. Nothing is being left unexamined: how care is delivered, where and by whom, how much it costs, how it is paid for, whether patients can make better decisions with more easily understood and available information. All of that will take time. Meantime, the good and honorable work of our health care system continues.
COLORADO DATA Population (2010 Census): 5,029,196 Children (Under 18): 24.4 percent Working age adults (18-64): 64.7 percent Seniors (65 and Older): 10.9 percent Median Income (2006-2010): $56,456 Sources: Page 60
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First-time father Joel Waller watches while Montrose Memorial Hospital personnel examine his newborn son following the early morning delivery. // Photos by Brian Clark 6
Nurse Midwives of MMH // Montrose One thing about babies is that they rarely arrive exactly on schedule. But when nurse-midwife Shauna Jones told expectant mom Johnna Ditton on a rainy summer night, “Oh, this baby will be here before sunrise,� it was a safe bet a baby was on the way. Jones, a Kansas City native, has helped deliver more than 300 babies during her 13-year career. Sure enough, Xavier John Clayton Waller was born at 2:40 a.m. on Thursday, August 23, 2012, three weeks ahead of his due date but happy and healthy. Xavier was the second of four babies that Jones helped deliver in a 48-hour period, with pockets of sleep and a few trips to let her dog out sprinkled in between.
8:08 p.m. Joel Waller and Johnna Ditton have just received the go-ahead from nursemidwife Shauna Jones to check in to Montrose Memorial Hospital. The couple lives in Norwood, more than 60 miles away, but MMH is the closest birthing facility to their house. Johnna had been trying to kick-start her labor all day after having pre-labor the day before.
11:09 p.m. After checking on Johnna, Jones heads to her office across the street from the hospital to catch up on work and grab some sleep on a couch in the lobby. Jones had been up most of the previous night assisting with another delivery. She left word to be notified when the birth appeared imminent. 7
1:42 a.m. Back at the hospital early Thursday morning, Jones coaches Johnna, who is nearly ready to begin pushing. 8
2:40 a.m. Xavier John Clayton Waller – weighing seven pounds, six ounces – arrives three weeks early but happy and healthy.
3:26 a.m. Joel hands her newborn son to Johnna for the first time. Johnna’s daughter, Zoey Ditton, 4, and sister, Melanie Christian, look on. Zoey was born in the same room at the hospital. 9
A young patient undergoes a dental exam at the Mountain Family Health Centers clinic in Rifle. The clinic’s five-station dental suite is a first for Mountain Family, a community health center. // Photo by Brian Clark
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CHAPTER 2
Health and Our Most Vulnerable Caring for Colorado’s most vulnerable residents is a challenging proposition, especially in the wake of a recession that has subtracted thousands of jobs, along with the employeesponsored health insurance that many families relied on. At the same time, the cost of providing public insurance has grown. Colorado has nearly 650,000 residents enrolled in Medicaid – a historically high caseload – and nearly 86,000 enrolled in the Child Health Plan Plus (CHP+) program, according to the Colorado Department of Health Care Policy and Financing. The level of enrollment is placing an unprecedented strain on the state budget and instilling a sense of urgency to make these programs more cost-effective. Colorado’s health care safety net fills some of the gaps, although waiting lists have lengthened. And a culture of caring plugs some holes as well. But for the state’s most vulnerable, finding good, affordable health care is not easy.
COLORADO DATA No health insurance: 829,000 (15.8 percent) Age group most likely to be uninsured: Young adults between 19 and 34 (27.7 percent) Racial/ethnic group most likely to be uninsured: Hispanic (26.3 percent) Children without health insurance: 112,200 Children living under the poverty line (2008-2010): 18.3 percent Sources: Page 60
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A three-year-old patient looks up while Dr. Patricio Gonzalez talks to his father about options for dealing with the boy’s tooth decay at a clinic in Rifle. Mountain Family Health Centers also has clinics in Black Hawk, Glenwood Springs and Basalt. // Photos by Brian Clark 12
Mountain Family Health Centers // Rifle The three-year-old patient looks up at the dentist, awed by the shiny equipment, unaware that he is already headed down a bumpy road when it comes to dental health. His family makes too much money to qualify for Medicaid but not enough to afford $5,000 to treat the decay that affects nearly every one of his teeth. Dr. Patricio Gonzalez sees problems like this on a regular basis at the Mountain Family Health Centers dental clinic in Rifle, where the ideal treatment is rarely in line with what patients in the economically depressed region can afford. The Chilean-born dentist grew up in St. Louis, gaining a passion for community dentistry after working in an inner-city clinic and from his own experience as an immigrant.
Dr. Gonzalez looks over an X-ray of an adult patient who has had several teeth extracted. “A lot of what we do is extractions,” Gonzalez said. “Then we can concentrate on the teeth they do have.”
“The degree of emergencies is different here than in private practice,” Dr. Gonzalez said. “There are a lot of dental needs like broken teeth, abscesses, infections and missing teeth.” More than a third of the clients are covered by Medicaid while another third are uninsured. 13
Las Animas Helping Hands // Bent County Sharon Barber once drove a Bent County woman the 200 miles to Denver and waited with her for five days while she received critical medical care. That’s not out of the ordinary for Barber, who started Las Animas Helping Hands in 2003 with her husband. Helping Hands routinely drives people to doctor’s appointments, pays for their prescriptions, arranges funds for their electric bills and delivers fresh food to their doorsteps. “We work from a health standpoint,” Barber said. “We try to help people become self-sufficient, but anyone who needs help gets it.” Helping Hands receives grants and some financial support from local groups. But one community member confided that Barber often uses her own money when funds are low.
Sharon Barber, left, delivers fresh vegetables to Barbara Garrison, who buys her food with the $17 in food stamps she receives each week. “Without Sharon I wouldn’t be able to afford fresh vegetables,” Garrison said. Barber’s nonprofit provides food for hundreds of people in Bent County. After receiving her vegetable delivery, Garrison remembered she had some frozen meat she wasn’t going to use, so she gave it to Barber to redistribute. 14
Raymond Gonzales carries a fresh zucchini, part of a vegetable delivery made by Barber. Gonzales has Medicare insurance and receives Social Security payments and his wife is covered by Medicaid. But Gonzales said their food stamp allotment was recently cut from $162 a month to $40 a month. “Sometimes I get overwhelmed with the poverty here,” Barber said. “It’s hard to express how hard it is to live in poverty in southeast Colorado.”
“I get paid in hugs,� said Barber, right. About 6,500 people live in Bent County, with nearly a quarter below the federal poverty level. // Photos by Brian Clark 15
Julie Zavala, a Certified Pediatric Nurse Practitioner (CPNP), performs a wellness exam on a young patient at the Kids Clinic at Crawford Elementary School in Aurora. The Rocky Mountain Youth Clinics’ two school-based health centers in Aurora are at Crawford and Laredo elementary schools. // Photos by Brian Clark 16
The Rocky Mountain Youth Clinics // Aurora Many health care providers drive to their place of work each day. Not as many actually drive their place of work. But for Trisha Hobart, a dental hygienist with The Rocky Mountain Youth Clinics, delivering one of the three Ronald McDonald Care Mobiles to its daily location is just another part of the job. From its start in 1996, RMYC now provides more than 50,000 visits at 40 clinic sites each year, one of the largest safety-net providers in Colorado. The network includes two school-based centers and the mobile clinics in Aurora that offer low-cost services such as immunizations, wellness exams, lab tests, routine dental care and mental health counseling.
A family leaves one of The Rocky Mountain Youth Clinic’s Ronald McDonald Care Mobiles. There are three mobile units in the fleet, one medical, one dental and one that offers both services. More than 3,000 children were treated between July 2010 and July 2011.
A mother and her daughters leave The Kids Clinic at Crawford Elementary following the girls’ wellness checkups. The RMYC’s medical home model makes it possible to offer care to children at its mobile, community and school-based sites. 17
La Puente // Alamosa For many in the San Luis Valley, life is harsh. Three of the valley’s six counties rank among the 10 poorest in the state. The valley’s median household income is less than two-thirds of the statewide median household income. Add to that a large contingent of migrant workers who descend on the area during harvest season, and the problems can seem overwhelming. La Puente, a nonprofit network, provides much-needed help. An emergency shelter in Alamosa is at the heart of its mission. Guests will find a bed, a hot meal, clothing, hygiene kits, medical referrals – even some hope.
A volunteer from a local church dishes out a fresh fruit salad during lunch at La Puente. Volunteers serve about 100 meals a day, according to shelter director Tona Ruybal. La Puente coordinates services with local mental health and medical clinics. It also operates several local businesses to earn funding. 18
U.S. Army veteran and retired restaurateur Lee Walters has volunteered at La Puente for 19 years. His fellow volunteers call him the “Kitchen Colonel,” a title Walters wears with pride. “They tried to offer me a little money during migrant season because it’s so busy,” Walters said. “I told them the day they try to pay me is the day I’m out of here.”
In town to work on the San Luis Valley potato harvest, Santiago Quintana takes a break outside the La Puente Emergency Shelter in Alamosa. Quintana, who is from New Mexico, travels to different states as he follows the harvest. // Photos by Brian Clark 19
Expectant father Jake Garner listens as his girlfriend, Jentrie Ribera, talks to Dr. Bethany Kolb. Her office handles all but the highest-risk pregnancies in the San Luis Valley, an area roughly the size of New Jersey, with six counties and approximately 46,000 residents. // Photos by Brian Clark 20
San Luis Valley Regional Medical Center // Alamosa People don’t hesitate to ask Dr. Bethany Kolb about her plans. “I have patients say straight to my face, ‘Are you going to stay?’ ” Such is the plight of rural areas like the San Luis Valley, where it can be difficult to find doctors who want to stick around. Kolb – a former accountant with an MBA – is one of two doctors in the Obstetrics & Gynecology office at the San Luis Valley Regional Medical Center, a nonprofit provider. Kolb’s patients may be in luck. If her deep commitment to practicing rural medicine isn’t enough, the area’s excellent fly fishing might just seal the deal. Part of what sold Kolb on the idea of working in Alamosa was a fly fishing outing she went on while in town for her interview.
Dr. Kolb visits with Bonnie Stone for a follow-up exam 21 weeks after the birth of Stone’s son. Kolb has brought innovative ideas about women’s health to Alamosa, including “Pappy Hour,” when women can gather for refreshments, door prizes, Pap smears, mammograms, chair massages and medical education.
Dr. Kolb checks her calendar while meeting with Cindi Oringdulph, who is ready to give birth to, as the expectant mother calls it, “Mega Baby.” Kolb expects to help deliver 30 babies over an upcoming two-week period. With that type of schedule, she may have a shot at breaking her personal record of delivering two babies in six minutes. 21
Violet Rodighiero paints during an art class at the Colorado State Veterans Nursing Home in Walsenburg. Ione Glumac, a retired band director and music teacher, volunteers to lead the class for three hours each Friday. // Photo by Brian Clark
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CHAPTER 3
Health and Our Seniors Seniors represent the fastest-growing age group in Colorado – and potentially one of the biggest stress points in the state’s health care system. Projections call for nearly a million Coloradans to fall within the 65 and older age group by 2030, an increase of 130 percent from 2000. These members of the Baby Boom generation will require more health care and more expensive health care. They may be more inclined to stay in their homes than move into care facilities. In Colorado, the Department of Health Care Policy and Financing is developing a five-year strategic plan to improve care of the state’s seniors, including efforts to better monitor the performance of facilities and move some eligible seniors back into their communities.
COLORADO DATA Coloradans 65 and older: 549,625 Percentage of the state population: 10.9 Percentage growth, 2000-2010: 32.1 percent Projected growth 2000-2030: 130 percent Percentage of Medicaid enrollees: 7 percent Percentage of Medicaid expenditures: 26 percent Sources: Page 60
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Park Beatty shares a tender moment with his wife, Gladys, following lunch at the Colorado State Veterans Nursing Home in Walsenburg. “That is often how we see them, whether in their room watching TV or sitting at their dining room table,” said Marty Schlink, the home’s administrator. “It truly is sweet.” Park and Gladys met in San Diego while both were serving in the U.S. Navy near the end of World War II. They’ve been together ever since. // Photos by Brian Clark 24
Colorado State Veterans Nursing Home // Walsenburg When a resident dies at the Colorado State Veterans Nursing Home in Walsenburg, the staff follows “Code Love.” The veteran’s body is draped in an American flag and taken out through the main doors, past fellow vets, volunteers and staff members who line the hallways to offer one final salute. Executive Director of Marketing Michelle Parks talks about “Code Love” with emotion crackling in her voice, having said farewell to a resident earlier that morning. Progressive approaches to senior care are widespread at the southern Colorado veterans’ facility – one of five veterans’ homes in the state. The goal is to create a meaningful place that honors the past and respects the present and future.
Gladys Beatty waits in the hallway in front of her room in the Military Drive wing of the nursing home. The facility is divided into mini neighborhoods named Military Drive, Freedom Lane and Liberty Lane. Neighborhood residents golf, fish and play cribbage,
watch local high school football games and travel to Taos, N.M., and other places. Behind Gladys is a board titled “Heroes of Military Drive,” featuring pictures of residents in their military uniforms. Right, a picture of Gladys and Park hangs on the board (bottom center). 25
Nurse Frances Jeppsen helps Park adjust his hearing aid. The nursing home is attached to the Spanish Peaks Regional Medical Center, a Trauma Level 4 critical access hospital. Five doctors from the hospital make routine rounds at the home. One of the doctors has a homeopathic background, an approach that is becoming increasingly popular with the Baby Boomers now coming to live at the home. 26
Jeppsen gives Gladys a hug after finishing her visit. “A lot of people who live here don’t have relatives nearby, so to the staff these aren’t residents, they’re extended family,” said Michele Parks, executive director of marketing at the hospital and the nursing home. A picture of Gladys from around the end of World War II, standing in front of a Navy building and wearing a grass skirt she got from Park, sits in the foreground.
Gladys and Park head down the hall to watch a group of Native American dancers who were performing for the residents. Gladys, the faster of the two, occasionally stops and waits for her husband to catch up. “God put us together,” Park says of his wife of 66 years. “We live a happy life.” 27
Zion Senior Center // Denver The former pro football player strikes an imposing presence as he leads the exercise class. But this is no ordinary class. The youngest participant is 65. The oldest is her 99-year-old mother. Rudy McClinnon, 60, a former draft pick of the Cincinnati Bengals, started leading the exercise program at northeast Denver’s Zion Senior Center in 2008. The funding ran out in 2011, but Rudy still shows up three times a week. McClinnon’s class is one of the activities offered at the center with the support of the Center for African American Health, a community-based group that partners with health education and health delivery organizations to promote wellness in the African-American community.
Rudy McClinnon leads exercise class participants through a workout at the Zion Senior Center in northeast Denver. In addition to McClinnon’s exercise class, the center provides seniors with a place where they can meet, receive routine health care services and participate in community activities. People can often be found inside playing a spirited game of dominoes or outside tending to the center’s garden. 28
A participant takes notes during the A Matter of Balance class, which helps seniors manage their fear of falling and emphasizes strategies for maintaining a physically active lifestyle. David Washington of the Center for African American Health arranged to offer programs like the balance class and McClinnon’s exercise class at Zion after seeing how much his mother enjoyed spending time at the center.
McClinnon jokes with class participant Dorothy Stockton-King while demonstrating an exercise technique. McClinnon volunteers up to three times a week. “You have to give back to the community,” he said. McClinnon’s only payment comes from a donation box on top of a glass display case at the front of the senior center. // Photos by Brian Clark 29
Dr. Melissa Helms, a primary care physician, talks with patient Bonnie Nelson at the Applewood Internal Medicine Clinic in Golden. // Photo by Chris Schneider
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CHAPTER 4
Health and Our Caregivers They are on the front lines of health care in Colorado. Physicians, clinical social workers, doctors of osteopathy, dentists, nurse practitioners, physician’s assistants, midwives, psychologists, registered nurses, and many, many more. Colorado’s caregivers form the heart of the state’s health care system, working at all hours, in all corners of the state, in many different settings, often making life and death decisions. In many cases, these caregivers are leading the charge to transform the system and participating in the discussions that will allow for new roles for caregivers – and indeed, new definitions of care-giving.
COLORADO DATA Active licensed physicians, 2005: 11,626 Active licensed physicians, 2011: 13,837 Physicians per 1,000 residents: 2.6 Counties without an active licensed doctor, 2011: Bent and Washington Percentage of female rural physicians: 29 percent Sources: Page 60
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Denver Health Emergency Department // Denver The ambulances seem to arrive in waves, each delivering patients in varying levels of distress. A woman who suffered a seizure and lost consciousness. A man shaking with tremors and unable to move his arm. Multiple people complaining of chest pains or irregular heartbeats. A homeless man with a history of drug and alcohol abuse, well-known to hospital staff. Each year more than 22,000 people pass through the Denver Health Emergency Department, the front door to Denver Health’s Rocky Mountain Regional Level I Trauma Center. For each patient, the doctors, nurses and medical technicians assess the severity of the situation and provide immediate care. Many of the decisions facing these front-line medical providers are a matter of life and death.
Fourth-year resident Anna Engeln works with fellow medical personnel in the Emergency Department at Denver Health.
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A Denver Police Department officer watches as paramedics bring in a patient at the emergency department at Denver Health. Security is often a top concern at the urban hospital.
Medical personnel gather to discuss patients currently being treated in the Emergency Department at Denver Health. // Photos by Chris Schneider
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Second-year medical student Racheal Gilmer, left, observes an inmate discussing her condition with Dr. Lindsey Fish. “Before I started (working at the prison) I was not sure if I could handle the environment. I was not sure if I would have thick enough skin or feel safe enough to work there every day,” Gilmer said. “After the first day, I was so pumped to keep working there. I love it. Now every time I think of my future, I think of how I can fit working at a prison into my plans.” // Photos by Brian Clark 34
Denver Women’s Correctional Facility // Denver Racheal Gilmer sits down to transcribe her examination notes in a clinic that looks like many others in Colorado. A fresh sheet of protective paper covers the exam table in the corner. A container of tongue depressors sits on the counter near a stack of medical files. But just then an armed guard leads a handcuffed patient down the hallway past the exam room. Gilmer, a second-year University of Colorado School of Medicine student, is inside the Denver Women’s Correctional Facility, where she is participating in a track for those interested in working with urban underserved communities. Gilmer gets valuable experience while treating members of the only population in Colorado for which health care is constitutionally guaranteed: prison inmates.
Gilmer examines an inmate at the Denver Women’s Correctional Facility. Gilmer is working and learning at the prison as part of a longitudinal track that gives medical students experience working with underserved urban populations. She learned about the prison opportunity during a school tour.
A guard leads an inmate down the hall in handcuffs past the office where Gilmer is preparing to present a report of a recent patient examination. Gilmer performs physical examinations on new inmates and records their medical histories. She then presents a report of the exam to Dr. Fish, who offers feedback and follows up with the inmates. 35
Applewood Internal Medicine Clinic // Golden Dr. Melissa Helms meets with patient Jennifer Apel near the end of an afternoon of appointments at the Applewood Internal Medicine Clinic in Golden, part of the New West Physicians primary care group practice. Apel is frightened, worried about a recurrence of the non-Hodgkin lymphoma she had battled in her 20s. She finds a caring and understanding physician in Dr. Helms, who participated in the Foundations of Doctoring curriculum at the University of Colorado School of Medicine. The program emphasizes compassionate treatment of patients, respect for their dignity, collaboration with other caregivers and the highest of clinical knowledge and skills.
Dr. Melissa Helms, a Colorado native from Littleton, realized she wasn’t in love with neurology during her clinical rotation as a third-year medical student and switched her focus to primary care. 36
Dr. Helms examines Jennifer Apel, who battled non-Hodgkin lymphoma when she was in her 20s. Apel recently began feeling pain similar to the pain she felt before her original cancer diagnosis. Dr. Helms ordered tests that will help to answer her patient’s concerns.
Dr. Helms examines patient Jeanne Wells, who was recovering from a back fracture. As a primary care physician, Helms sees a wide variety of patients, from those who visit once a year for a routine physical to those with severe chronic conditions. // Photos by Chris Schneider 37
After her residency at Alamosa’s Valley-Wide Health Systems dental clinic ended in 2010, Dr. Aimee Larraga, right, wanted to remain at the community health center. Larraga took advantage of the Colorado Health Service Corps, which provides educational loan relief in exchange for a three-year commitment to work in an underserved area. Larraga was able to remain at Valley-Wide and is becoming a fixture in the community. // Photos by Brian Clark 38
Colorado Health Service Corps // Statewide It had been several years since a dentist had stayed at Alamosa’s Valley-Wide Health Systems clinic after completing the one-year residency. So Dental Director Nancy Rosenthal was thrilled when Dr. Aimee Larraga said she wanted to continue working at the clinic after her residency ended in 2010. Rosenthal was also happy that the Colorado Health Service Corps could make that happen. Larraga was accepted into the program, which provides debt forgiveness in exchange for a three-year commitment to work in an area with a shortage of health care professionals. She has gone on to become a fixture in the community. “Dr. Larraga is a real success story,” Rosenthal said. “It’s hard in rural areas to find the right fit. Loan repayment really helps with recruitment.”
Many of the health care professionals featured in this book also participated in the corps. Clockwise from left: Nurse Midwife Shauna Jones Nurse Midwives of MMH, Montrose (pp. 6-7) Dr. Patricio Gonzalez Mountain Family Health Centers dental clinic, Rifle (pp. 12-13) Dr. Bethany Kolb San Luis Valley Medical Center, Alamosa (pp. 20-21) Dr. Colby Jolley, Haxtun Hospital District, Haxtun (pp. 44-45) Dr. Michael Dow, People’s Medical Clinic, Boulder (pp. 50-51) 39
Led by director Mary Beauchamp, center, volunteers from the Las Animas Community Garden prepare to deliver a fresh harvest of vegetables to seniors at the nearby Bent County Health Care Center nursing home. When the weather is nice, residents of the home can often be found around the edges of the garden, checking on the progress and offering advice to the volunteers. // Photo by Brian Clark
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CHAPTER 5
Health and Our Communities Colorado’s communities are working as never before to help their citizens lead healthier lives. Across Colorado, community members are planting gardens, upgrading playgrounds, challenging their neighbors to be active, tackling the problem of food deserts and adding bicycle lanes. Studies show that a focus on population health – and especially preventive measures – can provide a strong return on a community’s investment. This work by communities comes as Colorado finds itself confronting some worrisome trends. While still one of the nation’s leanest states, Colorado’s obesity rate has doubled in fewer than 20 years and topped the 20 percent level for the first time in 2010. More than half of Colorado adults are overweight or obese and one of every eight children between the ages of 2 and 14 are obese.
COLORADO DATA Percentage of adults who smoke cigarettes: 17.3 percent Percentage of adults reporting they were diagnosed with high blood pressure: 17.0 percent Percentage of high school students (ninth through 12th grade) who smoke: 17.7 percent Percentage of adults who binge drink: 17.7 percent Sources: Page 60
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Volunteers Don White and Caitlin Johnson look for weeds in a crop of cucumbers. White, 79, is a retired teacher, sculptor and artist who delivers vegetables to residents of a nearby retirement village several times a week. Johnson, a high school senior, designed the garden’s water-saving irrigation system. // Photos by Brian Clark 42
Las Animas Community Garden // Las Animas Southeast Colorado knows a thing or two about harsh drought conditions. So to say that the brightly colored Las Animas community garden stands out as a jewel is an understatement. Even as the temperatures soar above 90 degrees for yet another day in the record-hot summer, volunteers of all ages toil in the lush green field located behind the combined middle school and high school. Don White, 79, tenderly checks on a small cherry tree he rescued from near death. First-graders Grace Gardner and Conan Tyler take a break from picking fresh tomatoes to devour a few of the juicy red treats. The garden began in 2007 to provide for community members in need and to combat the county’s high obesity rate. Today, it provides food for about 600 people, from the low-income to the elderly to students who enjoy fresh fruits and vegetables at school salad bars.
First-grader Grace Gardner, 7, enjoys a fresh tomato grown at the Las Animas Community Garden. Fresh produce from the garden is circulated throughout Bent County and the surrounding area, where adult obesity rates are among the highest in the state and nearly a third of the children are considered obese or overweight.
High school students tend to the crops during their garden and greenhouse class. The community garden is located behind the combined middle and high school. Teacher Susan Coulter leads six classes a day at the garden. Nearly 600 people – including students, seniors and low-income families – receive produce from the garden. 43
Community Weight Loss Class // Haxtun In a small town, when someone makes a life-changing difference, it does not go unnoticed. In Haxtun, that someone is Dr. Colby Jolley. A primary care physician at Haxtun Hospital, Jolley started a weight loss class in 2010. During the 12-week sessions, she offers information on portion control, emotional triggers and maintaining a healthy lifestyle. Participants pay a $30 registration fee, but get a refund if they meet their weight loss goal. Members of the class nominated Jolley for the 2011 Country Doctor of the Year Award. “This is unlike any other diet or weight loss program I have tried,” said Bonnie Biesemier, 80, who has been with the program since it started. “I like the education and accountability.”
During the 12-week weight loss class, participants keep a detailed food journal to increase their awareness about what, how much and how often they eat. “This isn’t a diet program” said Dr. Colby Jolley. “It’s about lifestyle.” The success of the program has spurred the creation of other healthy initiatives in Haxtun, including yoga, Pilates and Zumba classes. 44
“Check out my muscles,” Haxtun resident Bonnie Biesemier, 80, said while stacking chairs at the end of Dr. Jolley’s weight loss class. Beisemier has been attending the class since it began in 2010. “I must really like it because I keep coming back.” No longer considered obese, her new goal is to lose 10 more pounds in the coming year.
Dr. Jolley proudly shows a slide featuring the total amount of weight that members of her class have shed since the program started in 2010. She makes sure to stress the half pound in the total. In a community with one of the highest obesity rates in Colorado, every little bit makes a difference. // Photos by Brian Clark 45
Colorado Plains Medical Center CEO Mike Patterson tries to take a picture of a few camera shy youngsters during a tour of the hospital’s helipad. The helipad was built in 2004-2005 with funds raised during the “Building the Rainbow” community campaign. Prior to that, the helicopter landed across the street at the high school, which often caused logistical issues when transporting critical patients. // Photos by Brian Clark 46
Colorado Plains Medical Center // Fort Morgan Two young boys cling tightly to their grandmother as they approach in wide-eyed wonder. They live just blocks from the Colorado Plains Medical Center in Fort Morgan and run out to wave at the North Colorado Med Evac helicopter every time it passes overhead. Now, they are seeing it up close for the first time during a tour of the helipad during the hospital’s anniversary celebration. The medical center celebrated 60 years of serving the Fort Morgan community in August. While the helicopter takes patients to bigger hospitals when the need arises, the goal of Colorado Plains Medical Center is to make sure patients receive top-notch medical care locally. The hospital is equipped with the latest in medical equipment and information technologies.
Dr. William Sammond of Heart Center of the Rockies shows a young Fort Morgan resident how to listen to her heartbeat during the community celebration. The hospital, which serves a two-county area in northeast Colorado, operates under the motto, “That we may leave to our children a heritage worthwhile.�
As part of its celebration, Colorado Plains Medical Center donated money to several worthy community groups. Eighteen organizations were listed on a ballot and the top six vote getters, as determined by Fort Morgan residents, each received $1,000 from the hospital. The medical center donated $100 to each of the other 12 nominees. 47
Palliative care nurse Maria Mosman, left, talks to Victoria Duncan, 32, during a home visit in August. Victoria was diagnosed with mesothelioma, a rare cancer, in 2011. // Photo by Brian Clark
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CHAPTER 6
Health and Our Innovation Today’s health care system isn’t designed to handle tomorrow’s health care needs. In many cases, the ever-increasing costs of health care already make it difficult or impossible for Coloradans to find good care that they can afford. Across Colorado, work is underway to transform how health care is delivered. Colorado’s best and brightest are determined to create a system that ensures Coloradans have a good care experience, that they emerge healthier and that the work is done in a more cost-efficient manner. Dozens of programs testing new ideas have been launched across the state.
COLORADO DATA Estimated waste in the health care system: 30 percent ($750 billion nationally) Number of primary care practices in the Colorado Comprehensive Primary Care Initiative: 73 Health care organizations connected to the Colorado Telehealth Network: More than 200 Number of patients enrolled in Colorado’s Medicaid trial program to reduce costs: More than 125,000 Sources: Page 60
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Dr. Michael Dow, a psychiatrist, meets with Peter, a member of Boulder’s homeless community, at People’s Medical Clinic, part of Clinica Family Health Services. With behavioral health professionals assigned to each integrated medical team, clinicians don’t have to spend valuable time diagnosing and treating patients who may benefit from a mental health consult. // Photos by Brian Clark 50
People’s Medical Clinic // Boulder Dr. Michael Dow sits on a low bench in his office, at eye level with Peter, a homeless man who has been sent to see the psychiatrist at the People’s Medical Clinic in Boulder, part of the Clinica Family Health Services network. Dr. Dow talks with Peter, then makes phone calls, coordinating Peter’s care with other clinicians in his office as well as the Boulder Shelter for the Homeless. This is how care works at the community health center, which is earning national attention for its innovative primary care treatment. Serving a low-income and uninsured population in Boulder County, Clinica uses a coordinated-care model with smaller, patient-centered medical homes within the larger organization. It integrates behavioral health professionals (BHP) into the mix. This saves the patient from setting up another appointment at another facility in yet another health care system.
Making a follow-up telephone call to a patient is part of the routine for Dr. Dow. Behavioral and mental health needs tend to be prevalent among low-income and uninsured patients, which make up a large percentage of Clinica’s patient base.
Physician’s assistant Emily Barnak compares notes with Dr. Dow on a patient they believe would benefit from a behavioral health consultation. Clinica is committed to treating the whole patient – body and mind. 51
Marillac Clinic // Grand Junction The spirit of Saint Louise de Marillac, the Patroness of Social Workers, courses through the Marillac Clinic in Grand Junction. The clinic was established in 1988 with the belief that all members of the Mesa County community, regardless of socioeconomic or insurance status, should have access to the entire continuum of health care services. Those services include medical, dental and optical clinics, integrated mental health care and chiropractic treatment. This integrated approach to community health care is at the heart of Marillac’s core values: to honor the health of the whole person – spiritual, psycho-social, emotional and physical. Since its inception, Marillac has provided more than 372,000 health care visits.
Optometrist Michael Reader Jr. examines a patient at the Marillac Clinic optical clinic. Marillac began providing optical services in 1999 by contracting with area optometrists, but in 2006 brought the services on-site and hired a part-time optometrist with the help of a three-year grant. In 2011, 1,806 patients received optical services at the clinic. 52
Jeff McCloskey of New Life Chiropractic adjusts a patient at Marrilac Clinic. The chiropractic care program at the Grand Junction safety net clinic is made possible through three volunteers from New Life Chiropractic who come in to provide services for one day every other week.
Physician’s Assistant Johnathon Kupfner, center, and Nurse Practitioner Andrea Lamb discuss the status of a patient at Marillac Clinic. The Grand Junction safety net clinic was designed to serve vulnerable individuals and families who pay a portion of the cost of their care. A sliding scale fee structure makes access to quality health care more affordable for all residents of Mesa County. // Photos by Brian Clark 53
Northwest Colorado Visiting Nurse Association // Craig Afamiliar scene plays out across Colorado at the start of each school year: a daughter talks to her mother about trying out for the cheerleading squad. For Victoria Duncan, family moments like these take on extra urgency. The 32-year-old single mom has mesothelioma, a rare cancer. She is undergoing chemotherapy treatments, but there is a real chance the cancer will one day take her life. Palliative care nurses from the Northwest Colorado Visiting Nurse Association routinely visit Victoria and 13-year-old Melissa, 10-year-old Tabitha and 8-year-old James at their home in Craig to provide comfort and support.
Tabitha Duncan, 10, cuddles with a pillow she made in summer camp as she watches nurses care for her mother, Victoria. Although elements of palliative care have been offered for years, it is rapidly becoming more formalized and is being offered to more patients. 54
Vickie Duncan, Victoria’s mother, holds the “gratitude” artwork her grandchildren made during Thanksgiving. Spiritual Care Coordinator Sandy Beran organized the craft project to help Victoria’s children communicate their emotions.
From left, Beran, Vickie Duncan, Nurse Maria Mosman and Victoria Duncan in the basement room where Victoria receives her care. When Victoria was diagnosed with cancer, Vickie moved into her home to help care for Victoria and her three children. // Photos by Brian Clark 55
Victoria rests her hands on one of her family’s many stuffed animals as she talks with her palliative care nurses. 56
Victoria listens while her daughters Melissa and Tabitha talk to Beran, the spiritual care coordinator, about their summer vacations. 57
Health and Our Future Colorado is changing – and so is our health care system. We are growing older as more members of the Baby Boomer generation hit retirement age. We are becoming more diverse. More of us are obese or overweight. Consolidation and integration is changing the landscape of our health industry. And economic realities have shown us that how we deliver and pay for health care must change. While little about the future is certain, it is virtually assured that health care in Colorado will be transformed over the next 10 years. Helping to guide that transformation, to provide reliable data and insightful analysis, to point toward evidence-based options and cost-effective scenarios, to serve as a trusted advisor during fastmoving times, is CHI’s charge for the next decade and beyond. Still, as these pictures of health illustrate, the big hearts and strong commitments of Coloradans across the state, and throughout our health care system, will be important factors in how well we care for each other. At the end of the day, a helping hand and a big hug can make a difference.
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Dr. Melissa Helms hugs patient Jeanne Wells at the Applewood Internal Medicine Clinic in Golden. // Photo by Chris Schneider
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CREDITS: Photography: Brian Clark, Colorado Health Institute Chris Schneider, Chris Schneider Photography Digital Photo Imaging: Sally Clark, Sally Clark Photography Book Design: Brian Clark, Colorado Health Institute
On the Road Where we found our Pictures of Health
Book Editor: Deborah Goeken, Colorado Health Institute Published October 2012
Haxtun
Craig
All photos ©2012
Fort Morgan Boulder Denver
DATA SOURCES: Health and Our Lives (page 5) U.S. Census Bureau: http://1.usa.gov/8nZVKT Health and Our Most Vulnerable (page 11) 2011 Colorado Household Access Survey: http://bit.ly/R0waas 2011 Colorado Health Report Card: http://bit.ly/R0w0zY Health and Our Seniors (page 23) U.S. Census Bureau: http://1.usa.gov/QmboiW U.S. Census Bureau: http://1.usa.gov/RxMoEU Colorado Health Institute, Colorado Medicaid: Options for Cost Containment: http://bit.ly/PqUalM
Golden Rifle
Aurora
Grand Junction
Montrose Las Animas
Health and Our Caregivers (page 31) Coloradohealthinstitute.org, Data Repository: http://www.coloradohealthinstitute.org/data-repository/county/ Colorado Health Institute, A Profile of Colorado’s Rural Physicians: http://bit.ly/LrFkdo
Walsenburg Alamosa
Health and Our Communities (page 41) 2011 Colorado Health Report Card: http://www.coloradohealthreportcard.org/reportcard/2011/default.aspx Health and Our Innovation (page 49) Institute of Medicine, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, September 2012: http://bit.ly/TZ1iW2 Center for Medicare & Medicaid Services: http://1.usa.gov/OFNwoY CORHIO Connect E-Newsletter: http://bit.ly/K3pyR4 Colorado Department of Health Care and Financing, At a Glance, May 31, 2012: http://1.usa.gov/QCDk2u 60
Connecting with CHI Website: Coloradohealthinstitute.org is a constantly-updated resource for the health care community. CHI’s website offers a data repository, CHI’s insight and analysis and regular blog posts. Facebook: facebook.com/ColoradoHealthInstitute Twitter: @CoHealthInst
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CHI is a trusted source of independent and objective health information, data and analysis for the state’s health care leaders. CHI, celebrating its tenth anniversary in 2012, is funded today by the Caring for Colorado Foundation, Rose Community Foundation, The Colorado Trust and the Colorado Health Foundation. 303 E. 17th Ave., Suite 930, Denver, CO 80203 • 303.831.4200 coloradohealthinstitute.org