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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.
5
Who Else Should Be at the Table?
6
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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