Clinical-Community Connection to

Prevention/Intervention Programs through

the EMR

Janet Werst

Community Health Supervisor

Community Health Improvement

Need for Clinical-Community Connection

• Provider knowledge of programs

• Drive class/program enrollment

• Provide continuum of care

• Evidence-based programming with health outcomes

• Identify gaps in service

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“UCHealth’s Healthy Hearts program has been a godsend. It has given us

reason to hope that we can stem this serious epidemic (of childhood

obesity). Recently it has been extended to Greeley in Weld County which

has had a significant impact on the number of families we can treat. The

results have been shocking. The families are learning that their food choices

matter and that being physically active is important. I have tried counseling

for this at well child checks for twenty years now and have not had the

impact that this program has had.” ~Dr. Kolanz

Let’s Start at the Beginning

• Provider Interest

• Brainstorming—who is missing from the table

• Leadership support/Epic (EMR)

• Define process for referrals

• Marketing

• Training/communication

• Program outcomes and tracking

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Provider Interest

• Providers initially requested a way to connect patients to community-based wellness programming.

• Barriers providers face when making referrals.

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Who Else Should Be at the Table?

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HealthyU

REF2242

Epic (EMR) and Process for Referrals

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• Work que in EMR

• Identify a navigator

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Marketing & Training

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Marketing & Training

HealthyU Ambulatory Referral Talking Points

• Primarily non-clinical, community-based programming for

continuum of care.

• One stop referral that addresses identified health issues

and improves access to services among populations and

individuals in our service area.

• Integrates clinical and non-clinical services.

• Low/minimal cost

• Referral to community-based programs that integrate

effective strategies and proven methods that positively

impacts health and wellness.

• Offers programs for exercise, nutrition, disease

management, prevention and wellness.

• Programs primarily available in Fort Collins and Loveland,

with some in Windsor and Greeley.

• Referral Directory

• Referral phone line 495-8570

Communication

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• Referral follow-up with providers in

EMR

• Top-of-Mind awareness Newsletter

Outcomes

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• 468 unique referrals

• 100% of referrals were sent to a program for follow up

• Of the total referrals received, 48% of those patients engaged in a program to which they were

referred.

• Referrals from 41 zip codes around Northern Colorado

Questions

Janet Werst, Community Health Supervisor

janet.werst@uchealth.org

970.495.7504

Heidi Overacker, CHE, HealthyU Navigator

heidi.overacker@uchealth.org

970.495.8560

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