At Rocky Mountain Health Plans, we believe that the foundation of effective health care lies within our communities, ensuring the right care is delivered at the right time and in the right place. By integrating health services at the local level, we work to improve health outcomes and ensure that every Coloradan receives the care they need and deserve.
What Is Community Integrated Care?
Community integration refers to embedding health services within local communities to improve access, coordination, and overall health outcomes. This approach allows individuals to receive care in familiar, supportive environments, reducing barriers related to transportation, cultural differences, and socioeconomic challenges. Community integration prioritizes a whole-person approach and addresses physical health, behavioral health, and social determinants of health (SDoH).
The Purpose and Importance of Community Integration
The primary goal of community integration is to create a seamless, coordinated health care system that meets people where they are. By integrating health services into community settings, we:
- Improve access to care, particularly in rural and underserved areas.
- Enhance care coordination by connecting primary care, behavioral health, and social services.
- Address SDoH, including housing, transportation, food security, and education.
- Reduce health disparities by reaching vulnerable populations.
- Lower health care costs by emphasizing preventive care, early intervention, and coordinated services to reduce avoidable hospitalizations and emergency room visits.
Colorado Medicaid: A Champion of Community Integrated Care
Over the past decade, there has been a national shift toward integrating behavioral and physical health care.1 Additionally, federal, state, and local initiatives have been enacted to address SDoH, particularly within the Medicaid program. In Colorado, the Medicaid program is called Health First Colorado.
Colorado has been at the forefront of health care innovation, participating in numerous pilot models that promote integrated care and payment reform that emphasizes value over volume.
One of the most significant models began in 2014 when the Centers for Medicare and Medicaid Services awarded the state funding to implement the Colorado State Innovation Model (SIM). This approach ultimately transformed how health care is delivered and paid for in the state and accelerated integrated care. That same year, in collaboration with the state and participating providers, we launched PRIME, a state– and nationally acclaimed managed care payment reform and innovation program.
Today, Colorado works to advance community integrated health services through several initiatives and mechanisms:
- Home and community-based services (HCBS) waivers help individuals who meet specific criteria remain in their homes and communities. These waivers are part of long-term services and supports.
- Section 1115 demonstration waivers forgo certain provisions of the federal Medicaid statutes and allow states the opportunity to test new delivery and payment approaches.
- Regional accountable entities (RAEs, sometimes called accountable care organizations) are part of the Accountable Care Collaborative and aim to streamline and enhance care delivery. RAEs are responsible for coordinating care, managing provider networks, and administering payments for behavioral health services within their respective region. Rocky Mountain Health Plans serves as the RAE for Region 1.
Additionally, the state’s Behavioral Health and Integration Strategies Subcommittee reviews integration strategies executed by RAEs and providers, ensures care coordination and benefit comprehension, and identifies barriers to behavioral health care to help inform the development of new strategies.2
Our Commitment to Community Health
Our dedication to community integration is reflected in our collaborations and investments. We have allocated millions of dollars through one-time and recurring contributions to support local health initiatives. In 2024, we:
- Invested $4.1 million of RAE funds in the health neighborhoods to address SDoH, including program expansion for food service agencies, a transitional housing facility, client transportation, and home-based SDoH services. This one-time funding also supported the quality of and expanded access to behavioral and physical health care, as well as promoted health equity initiatives.
- Made $9.7 million in recurring investments, supporting community-based organizations, community-based care coordination teams, and primary care medical providers (PCMPs) to sustain integrated behavioral health and SDoH program staff.
- Provided more than $18 million in funding to PCMPs through transformative value-based payments, including capacity building to behavioral health providers to offer services integrated into community settings. Such services included school-based suicide prevention, peer outreach, supportive housing, and substance use disorder programs.
“Thanks to the generous and creative support and commitment of Rocky Mountain Health Plans, we’re opening programs and expanding current programs to serve historically underserved populations. … Additionally, the Mobile Diagnostic Unit — a joint initiative between Oliver Behavioral Consultants and Rocky Mountain Health Plans — began providing services in mid-October of 2023. … The initial successes exemplify the transformative potential of accessible care and underline the importance of OBC’s mission in facilitating health care equity in rural Colorado and Rocky Mountain Health Plan’s commitment to service and innovation.”
– Oliver Behavioral Consultants
Working Together to Build Healthier Communities
Embedding health care within our communities addresses immediate medical needs and fosters environments where individuals can thrive. Through collaboration and innovation, we can help all Coloradans get the accessible, equitable, and culturally sensitive care they deserve, when and where they need it.
1. Sandhu S, Sharma A, Cholera R, Bettger JP. Integrated Health and Social Care in the United States: A Decade of Policy Progress. Int J Integr Care. 2021 Oct 29;21(4):9. doi: 10.5334/ijic.5687. PMID: 34785994; PMCID: PMC8570194. https://pmc.ncbi.nlm.nih.gov/articles/PMC8570194/#:~:text=Recent%20Integrated%20Care%20Reforms%20in,integrated%20care%20programs%20and%20efforts.
2. Colorado Department of Health Care Policy & Financing. Behavioral Health and Integration Strategies Subcommittee. Accessed March 10, 2025. https://hcpf.colorado.gov/behavioral-health-and-integration-strategies-subcommittee