The report evaluates the Bridges to Care program and finds that: 1) The program significantly reduced healthcare utilization and costs for participants, with ER visits dropping from 4 to 2 visits on average and costs falling from $11,234 to $5,223 per participant over 6 months. 2) The program improved access to primary care, with 94% of participants having a PCP within 60 days and 24% of uninsured participants gaining insurance. 3) Participants reported significantly better health, with physically and mentally healthy days increasing by about 5 days. 4) Key services like care coordination and health coaching were identified as most important. The program achieved estimated savings of $1.1 million over 6 months for the 184 graduates

1. Bridges to Care Program Evaluation
Final Report
Prepared for Metro Community Providers Network
by
December 19, 2014
2601 S Lemay Suite 7, #109 Fort Collins, CO 80525 (970) 818-9309 www.SmithLehmann.com

2. Table of Contents
Introduction ....................................................................................................................................... 1
Methods................................................................................................................................ 1
Results................................................................................................................................... 1
Conclusions ....................................................................................................................................... 13
Recommendations............................................................................................................................. 13
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3. Introduction
The Metro Community Provider Network (MCPN) contracted Smith & Lehmann Consulting to determine
whether the Bridges to Care (B2C) program is effectively reducing unnecessary healthcare utilization;
identify key aspects of the program that are critical to success; and develop strategies for integrating key
aspects into existing service delivery once external funding for the program ends. The evaluation covers
these aspects of the program over the 2013-2014 timeframe.
Methods
Analysis of existing data
Smith & Lehmann analyzed MCPN’s existing data from the Bridges to Care program to identify the key
program components associated with success and cost-effectiveness. Data from Bridges to Care
graduates were used for this analysis. Over the 2013-2014 timeframe, an estimated 70% of B2C
enrollees successfully graduated from the program. Bridges to Care graduates needed to have at least
six months of hospital utilization data both prior to and following B2C enrollment to be included in the
analyses of cost savings and utilization reduction. All graduates were included in the analyses of self-
reported health status.
Administrative data analysis
Our team utilized data provided by MCPN to create a budget analysis. This analysis provided information
about Bridges to Care’s current and anticipated operating costs, including personnel, equipment, travel,
and training expenses. Smith & Lehmann analyzed projected operating costs and provided information
about estimated staffing levels necessary to maintaining a cost-neutral version of the program. The cost
calculations are based on the estimated costs of serving all enrollees; both program graduates and
program dropouts. The savings calculations are based on savings attributed only to program graduates.
Qualitative interviews
Smith & Lehmann staff conducted interviews with key MCPN staff and stakeholders to provide a
complete picture about the key services and service delivery priorities in Bridges to Care as well as the
unanticipated benefits or challenges of the program. These interviews also provided an opportunity for
a brief discussion of the program’s sustainability plans. Smith & Lehmann conducted one external
interview with the Manager of the Health Care Innovation Award at Truman Medical Center to gain
perspective on the similarities and differences between their model and the Bridges to Care program.
Results
Below are the results for MCPN’s Bridges to Care program evaluation. Results are organized by the key
evaluation questions. For the purpose of this analysis, high utilizers are defined as patients averaging
five or more visits, either emergency room (ER) or in-patient (IP) admissions, during the six months prior
to enrollment. Medium utilizers are defined as having four visits pre-enrollment, and low utilizers are
defined as having three or fewer visits during the six months pre-enrollment in the Bridges to Care
program. Owing to the preponderance of statistically significant results at the p<.05 level or better, all
results depicted in graphs are statistically significant, unless noted otherwise.
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4. Is the Bridges to Care program reducing utilization of the health care system?
♦ The average number of visits among Bridges to Care participants has been significantly
decreasing. For ER visits, the average has dropped from almost four visits prior to enrollment to
two visits after graduation; admissions have also seen a similar, significant drop (Figure 1).
♦ Among all utilizers, average number of ER visits and hospital admissions has shown a significant
decline post-graduation. The most dramatic differences tend to be the mid (four visits) to high
(five or more visits) utilizers, where their average number of ER visits decreases by about 3 visits
after graduating Bridges to Care (Figure 2). Hospital admissions have seen the most significant
change with the low and medium utilizers (Figure 3). This trend is logical due to the fact that mid
to low-utilizers generally frequent their primary care provider (PCP) more often than high-
utilizers who demonstrate more ER visits, and therefore mid- to low-utilizers have a greater
capacity to demonstrate a significant decrease in admissions.
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits
Figure 1. Average 6-month Hospital Utilization Among All B2C
Patients
ER visits Hospital admissions
0
1
2
3
4
5
6
7
8
Pre B2C Post B2C
#ofvisits
Figure 2. Average 6-month ER Visits by Utilization Level
Low Utilizers
Mid Utilizers
High Utilizers
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5. ♦ The Bridges to Care program has had a significant impact among uninsured and Medicaid
patients. The average number of ER visits from uninsured patients decreases from 3.8 visits pre-
enrollment to 1.8 visits after graduating from the program (Figure 4). Similarly, Medicaid
patients decrease their visits from 4.2 visits pre-enrollment to 2.8 visits after graduation (Figure
5). Hospital admissions have been significantly dropping among uninsured patients (from 0.7
visits pre-enrollment to 0.3 visits post-graduation); however, Medicaid patients have not
experienced a similar, significant drop (0.5 visits pre-enrollment to 0.3 visits post-graduation) in
hospital admissions.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Pre B2C Post B2C
#ofvisits
Figure 3. Average 6-month Hospital Inpatient Visits by
Utilization Category
Low Utilizers
Mid Utilizers
High Utilizers
*N.S.
*Not significant
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits
Figure 4. Average Number of 6-month
Hospital Visits by Uninsured Patients
ER Visits Hospital Admissions
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits
Figure 5. Average Number of 6-month
Hospital Visits by Medicaid Patients
ER Visits Hospital Admissions
*N.S.
*Not significant
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6. ♦ Utilization among patients who kept or gained a PCP during their time in the Bridges to Care
program also shows similar and promising results, based on self-report. The average number of
ER visits and hospital admissions of patients who kept or gained a PCP has been dropping
significantly upon graduating from the program (Figure 6 and 7). Patients who have a PCP 60
days into the program are significantly reducing their visits as well (Figure 8).
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits
Figure 8. Average Number of 6-month Hospital Visits of
Patients with PCP After 60 Days
ER Visits Hospital Admissions
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits
Figure 6. Average Number of 6-month
Hospital Visits of Patients Keeping PCP
ER Visits Hospital Admissions
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits
Figure 7. Average Number of 6-month
Hospital Visits of Patients Gaining PCP
ER Visits Hospital Admissions
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7. Even among patients without a PCP after 60 days, ER visits are still showing a downward trend,
from 3.1 visits before enrollment to 1.7 visits after graduation (Figure 9). Hospital admissions are
also going down; however, this is not a significant trend.
Is the program improving patient access to primary care providers (PCP)? Is the program increasing
access to health insurance?
♦ Overall results indicate that 94% of Bridges to Care participants have a PCP 60 days after
enrollment and 89% of those who did not have a PCP upon enrollment get one (Figure 10). As
noted earlier, this is based on self-reported data.
♦ Among all Bridges to Care participants, 67% keep their PCP after graduation, and 25% gain a
PCP. Five percent lose their PCP and 3% never gain a PCP.
0
1
2
3
4
5
6
Pre B2C Post B2C
#ofvisits Figure 9. Average Number of 6-month Visits of Patients
without PCP After 60 Days
ER Visits Hospital Admissions
*N.S.
*Not Significant
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Enrollment 30 days 60 days
Figure 10. B2C Patients with Primary Care Provider at
Enrollment and Follow-up
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8. ♦ Overall, 24% of all uninsured Bridges to Care participants have graduated with insurance in 2013
and 2014, to date. In 2013, approximately 13% of uninsured Bridges to Care participants gained
insurance at the time of graduation; this number increases to almost 40% in 2014 (Figure 11).
This increase indicates that Bridges to Care has been successful at linking patients into the
health insurance newly available under the Affordable Care Act.
Is the program successful at improving patients’ overall health and well-being?
♦ Participants in the program are showing significant health improvements (Figure 12). The
number of self-reported healthy days increases by at least five at 60-day follow-up. Most
notably, physically healthy days increase the most from about 10 days at enrollment to almost
19 days at follow-up.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
2013 2014
Figure 11. B2C Patients Gaining Insurance After
B2C Enrollment
0
5
10
15
20
25
Baseline 60 days
#ofhealthydaysinpast30
Figure 12. B2C Patients Increase Healthy Days
Physically healthy Mentally healthy No activity disruption
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9. What are Bridges to Care’s core services and non-essential services?
♦ The most important components, according to key
Bridges to Care stakeholders, are the care coordination and
team integration and the health-coaching component.
Connecting with the patient, taking “the time to identify their
specific and different needs,” is the most important aspect of
the program and is a core service provided by Bridges to Care
staff.
♦ The program gives PCPs outside of Bridges to Care a
“short intensive intervention to stabilize the patients” where
“most PCPs don’t have the time and resources to do that
stabilization.” It gives providers the extra and often needed
opportunity to help their patients put their lives back together.
♦ The behavioral health-coaching element found in
Bridges to Care is crucial due to high mental health concerns
among patients in Aurora. This is an element that is missing in
other MCPN programs.
♦ Connecting with patients right away, providing medical reconciliation and finding a primary care
home for patients are also very important services to the program.
♦ Stakeholders agree that the program’s services impact goes beyond the individual but also
impacts the community. Bridges to Care “helps to develop healthier individuals that are now
able to be more productive members of society.”
♦ The only group that does not see the benefits of Bridges to Care would be those with substance
abuse issues. There are no services in the program that would create the needed impact for
these individuals.
♦ Due to the integrated nature of the team approach to care coordination, it is difficult to
determine the existence of non-essential services within the Bridges to Care program.
Conducting a randomized study design and assigning different levels of certain services to
incoming participants will help answer this question.
What is the estimated cost savings of the Bridges to Care program?
♦ Overall gross costs have been significantly decreasing among Bridges to Care participants. On
average, before participants enter the program, each patient accrues $11,234 in patient care
costs over a six-month period. After graduating from Bridges to Care, average patient care costs
fall to $5,223 over a six-month period (Figure 14). This result indicates that by participating in
the Bridges to Care program, patient costs decreased by an average of $6,011 per participant
over a six-month period. Based on the assumption that a total of 184 patients graduated from
Bridges to Care during the time period of the analysis (all graduates through March 21, 2014),
total cost-savings of the program was approximately $1,106,024 over the six-month time period.
Smith & Lehmann only considered the effects of the intervention on six-months of post-
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10. utilization records. Further research would be necessary to assess the duration of the program-
effect on reduced utilization.
♦ When gross hospital costs are broken out month-by-month pre and post enrollment in Bridges
to Care, there is an overall downward trend (Figure 15). Patient costs gradually increase at
approximately four months pre-enrollment and then steadily decrease three months after
graduating from the program.
♦ Gross hospital costs declined significantly for each utilization group, as seen in Figure 16. The
estimated 6-month gross cost savings of Bridges to Care are $1,106,024, or between $4,254 and
$5,223 per graduate. Costs for low and medium utilizers were similar throughout. The Bridges to
Care program significantly reduced gross costs for high utilizers to just under the pre-enrollment
levels of the low and medium utilizers. Interestingly, Figure 17 shows that the gross costs for the
highest utilizers fall to be within the range of the low and mid-level utilizers by six months post-
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
6 mo.
Pre
B2C
5 mo.
Pre
B2C
4 mo.
Pre
B2C
3 mo.
Pre
B2C
2 mo.
Pre
B2C
1 mo.
Pre
B2C
B2C
mo. 1
B2C
mo. 2
1 mo.
Post
B2C
2 mo.
Post
B2C
3 mo.
Post
B2C
4 mo.
Post
B2C
5 mo.
Post
B2C
6 mo.
Post
B2C
Figure 15. Gross Monthly UCH Hospital Costs 6 Months Pre and
Post B2C
$0
$500
$1,000
$1,500
$5,000
$5,500
$6,000
B2C
Treatment
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
Pre B2C Post B2C
Figure 14. Change in Gross 6-month UCH Care Costs for
B2C Graduates
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11. graduation from Bridges to Care. What is unknown is whether that decline continues beyond
the six-month post-treatment mark, and if so, for how long are cost-savings sustained.
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
Gross costs pre B2C Gross costs post B2C
Figure 16. 6-Month Gross UCH Care Costs Before and
After B2C by Utilization Level
Low Utilizers Mid Utilizers High Utilizers
$0
$1,000
$2,000
$3,000
$4,000
$5,000
6 mo.
Pre
B2C
5 mo.
Pre
B2C
4 mo.
Pre
B2C
3 mo.
Pre
B2C
2 mo.
Pre
B2C
1 mo.
Pre
B2C
B2C
mo. 1
B2C
mo. 2
1 mo.
Post
B2C
2 mo.
Post
B2C
3 mo.
Post
B2C
4 mo.
Post
B2C
5 mo.
Post
B2C
6 mo.
Post
B2C
Figure 17. Gross Monthly UCH Hospital Costs 6 Months Pre and Post B2C
by Utilization Level
Low utilizers Medium utilizers High utilizers
$0
$1,000
$2,000
$4,000
$5,000
$6,000
B2C
Treatment
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12. What practices can be implemented to ensure the sustainability of the program?
♦ Key stakeholders agree that additional funding
is needed to sustain the program. Grants will not
always cover all the costs of the program.
♦ Stakeholders suggested melding Bridges to Care
into the Accountable Care Collaborative (ACC) or into
the greater MCPN population in order to continue
providing services after pilot funding for the program
has been expended.
♦ Through the pilot program, staff found that not
all patients need the 60-day program model. “Some
patients really don’t need this after one month, there
are certain people that are able to do a lot more on their own…I think that each patient is so
different, and it’s a good starting point but [now we should be] looking at the individualization of
the program per patient.” By creating guidelines for early graduation, MCPN could reduce the
overall cost per patient because patients with lower needs would help absorb some of the costs
of the higher needs patients that require a longer intervention.
♦ Moving providers back into the clinics has also been suggested as an adjustment to the current
model that would help to ensure sustainability. This does not mean losing touch with these
providers but rather allowing the community health workers, health coaches, and clinical care
coordinators to continue to work as a team, enhancing the link between the patients and their
providers at the MCPN clinic or otherwise.
♦ To be self-sustaining, stakeholders agreed that patients need to be enrolled in Medicaid more
quickly. To help with this, one stakeholder suggested having a technician help patients through
the enrollment process either once they enter the clinic or even during an in-home consultation.
♦ Stakeholders stressed the importance of
preserving the basic team-structure of the
Bridges to Care program and hoped the
lessons learned would be applied to other
programs resulting in an MCPN-wide care
coordination team.
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13. What staffing levels/configurations are needed to continue the program post-funding?
♦ Annual budget for the current Bridges to Care program is approximately $1.9 million after
accounting for incoming Medicaid reimbursements. While this budget exceeds MCPN’s ability to
continue the program, Smith & Lehmann examined two alternative budget scenarios
demonstrating the funding necessary in continuing Bridges to Care services.
♦ Alternative 1: One-Team Model
For this alternative scenario, Bridges to Care would reduce its model to one team consisting of
the following staff: advanced practice nurse (NP), medical assistant (MA), clinical care
coordinator (CCC), health coach (HC), and community health worker. Changes made to the
current Bridges to Care model under this alternative include: reducing the model to one care
team, targeting mid to high utilizers specifically, and expanding the program service area. This
alternative budget includes current project directors, a clinical operations manager, project
assistant, HR specialist, grant specialist, and administrative assistant (Table 1). This alternative
scenario also assumes MCPN will continue to contract with Aurora Mental Health for a
behavioral health provider (BHP) and a behavioral health case manager (BHCM). Administrative
staff levels remain similar to the current model because it is assumed that a push for continued
funding will be necessary to sustainability of Bridges to Care. Administrative staff will also need
to build relationships with additional hospitals and clinics to expand the reach of Bridges to
Care. Cutting staff back to one team instead of two will aid in decreasing costs, and under this
scenario MCPN would need to come up with approximately $793,672 per year to fund the one-
team model. While patients on Medicaid, and other forms of insurance, will provide a fractional
reimbursement, the current reimbursement rates are not adequate enough to ensure sufficient
reimbursement of program costs and should not be considered as a source of revenue in
sustainability planning.
Table 1. Projected B2C Budget: One-Team Model
Category Amount
Personnel $673,457
Equipment $1,700
Travel $4,900
Training $3,750
Aurora Mental Health Services $109,865
Total Annual Budget $793,672
♦ Alternative 2: MCPN Care Coordination Team
For this alternative scenario, the Bridges to Care services would be offered under an MCPN Care
Coordination team to patients identified as mid and high utilizers within the broader MCPN
population. Under this model, MCPN would reduce its care coordination team to consist of the
following staff: a clinical care coordinator (CCC), health coach (HC), and community health
worker. MCPN’s Care Coordination team would be established to target mid to high utilizers
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14. specifically, and be expanded to provide intervention services where the need is greatest. This
alternative budget includes one project director, project assistant, HR specialist, and
administrative assistant (Table 2). This alternative scenario also assumes MCPN will not continue
to contract with Aurora Mental Health for a behavioral health provider (BHP) and a behavioral
health case manager (BHCM). Administrative staff will continue to build relationships with
additional hospitals and clinics to expand the reach of MCPN’s care coordination services.
Cutting back on medical staff and bringing patients into the clinic to see their provider will
greatly decrease costs (by approximately $252,169), and under this scenario MCPN would need
to come up with approximately $431,638 per year to fund an MCPN Care Coordination team.
While patients on Medicaid, and other forms of insurance, will provide a fractional
reimbursement, the current reimbursement rates are not adequate enough to ensure sufficient
reimbursement of program costs and should not be considered as a source of revenue in
sustainability planning.
Table 2. Projected Budget: Extension Team Scenario
Category Amount
Personnel $426,448
Equipment $0
Travel $2,940
Training $2,250
Aurora Mental Health Services $0
Total Annual Budget $431,638
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15. Conclusions
The Metro Community Provider Network (MCPN) contracted Smith & Lehmann Consulting to determine
whether the Bridges to Care program is effectively reducing unnecessary healthcare utilization; identify
key aspects of the program that are critical to success; and develop strategies for integrating key aspects
into existing service delivery once external funding for the program ends. Smith & Lehmann’s evaluation
covered these aspects of the program over the 2013-2014 timeframe.
Smith & Lehmann analyzed MCPN’s existing data from the Bridges to Care program and identified that
all utilizers demonstrated a statistically significant decrease in the average number of ER visits and
hospital admissions after completing the Bridges to Care program. The most dramatic differences tend
to be seen in the mid to high utilizers, where their average number of ER visits decreases by about 3
visits after graduating Bridges to Care. Results indicate that the Bridges to Care program successfully
links patients to primary care providers. Overall results indicated that 94% of Bridges to Care
participants have a primary care provider (PCP) 60 days after enrollment and 89% of those who did not
have a PCP upon enrollment get one. In the effort to connect patients to insurance, 24% of all uninsured
Bridges to Care participants graduated with insurance in 2013 and 2014, to date. In 2013, approximately
13% of uninsured Bridges to Care participants gained insurance at the time of graduation; this number
increases to almost 40% in 2014. Overall results indicate Bridges to Care achieved a significant reduction
in utilization resulting in $1.1 million of patient cost savings realized over the treatment of 184 patients.
Recommendations
♦ Smith & Lehmann recommends MCPN expand the availability of Bridges to Care services to all
MCPN patients and strive to access the larger population of the greater Denver area. MCPN
should also discuss and consider expanding this program to different health care areas, such as
pediatrics.
♦ Smith & Lehmann recommends MCPN develop guidelines to allow for early graduation from the
program. Allowing the intensity of program services to fluctuate with individual patient needs
will decrease overall per patient costs because those with fewer needs will help absorb some of
the costs of the high-needs patients that require a longer intervention.
♦ Additionally, Smith & Lehmann recommends implementing a long term study to determine how
long the impact of the program lasts for participants. Having check-ins beyond six months will be
able to assess the need to develop “booster shots” where patients are reminded of what they
learned through the program and how to make better decisions with their health care.
Additional cost of “booster shots” would be minimal since patients would not be going through
the entire program again but would still be receiving the individual care and attention needed to
get them back on track.
♦ If MCPN wishes to determine whether a scaled-back (or lower-dose) Bridges to Care model will
be equally as effective as the current model, Smith & Lehmann recommends that MCPN
implement a randomized trial or a similarly rigorous study of alternative models. Under the
randomized trial, patients would need to be randomly assigned to receive either the current
model or a scaled-back model in order to rigorously assess whether outcomes would be the
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16. same for both groups. In order to test a customized-dosage model that provides early
graduation for clients showing rapid improvement, a historical control group of 2013-2014 B2C
graduates should be used to ensure that outcomes remain the same or better under the
modified model.
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