Executive Summary

The full summary report may be viewed here.

A series of key informant interviews were conducted with 21 health and social service organizations in La Plata County to elicit feedback on barriers clients face and gauge provider perspectives on the concept of a Community Care Hub coordination model. As leaders in the local health ecosystem, these stakeholders offered important insights into existing gaps and needs as well as recommendations that will shape efforts to enhance access and delivery of services.


In-depth interviews consisting of 11 open-ended questions were completed during January 2023. The questions covered topics such as client barriers around healthcare and social determinants, satisfaction with current referral processes, and concerns related to adopting new coordinated technology platforms. Detailed notes were analyzed through qualitative methodology to extract prevalent themes from the responses, which were quantified based on frequency of mention across the 21 interviews.


Challenges & Barriers
The most widely cited barriers clients face were around access to services (14 mentions), communication and coordination among agencies and providers (10 mentions), transportation (10 mentions), and cost (7 mentions), indicating substantial inequities.

Care Coordination Satisfaction
Coordination between organizations earned mixed reviews, with room for improvement in communication (9 mentions), sharing information about available services and resources (5 mentions). But some interviewees also noted “strong relationships.”

Referral Process Improvement
Many cite lack of a shared, centralized platform to track referrals and outcomes (9 mentions). Top concerns included challenges with existing technology platforms (8 mentions) including the added burden and integration complexity.

Adopting a Web-base Referral Platform
Participants express interest in a centralized software platform for managing client referrals but raise concerns about the potential complexity (14 mentions), data security and privacy (12 mentions), time investment to implement and use (11 mentions), cost (8 mentions) and interoperability with existing systems (5 mentions).

Participation in a Navigation Network
Support emerged for the potential value of coordination and information exchange benefits (18 mentions), though some cited time commitment and logistical concerns (14 mentions).

Organizational Capacity
Some organizations noted being at or near capacity (12 mentions) currently but many recognized the need for expansions and had the ability to scale up services if needed (8 mentions).

Backbone Entity
Respondents emphasize the importance of community input in running a CCH (13 mentions) with leaders having strong organizational capacity and expertise (12 mentions). Recommendations included creating a new entity (6 mentions), leveraging existing entities (5 mentions) but having neutral leadership without conflicts of interest (4 mentions).

Funding Approaches
There is strong agreement on the need for diverse funding sources (19 mentions) with multiple, collaborative funding models (18 mentions). Reliance on grants alone was seen as risky by many (14 mentions).

A diverse (18 mentions) and balanced governing body is needed with representation from the community and CCH organizations (14 mentions). 

Implementation Concerns
Broad concerns (23 mentions) emerged regarding time, cost and logistics of participating in a CCH. Seeing platform functionality and integration with existing tools (21 mentions) were commonly mentioned as important by interviewees, as was data privacy and security (14 mentions).

General Sentiments
Overall strong support (18 mentions) emerged for the concept of a CCH and respondents see the value in participation, partnership and collaboration (11 mentions).

Conclusion & Recommended Next Steps

The results of this study show a strong interest, particularly among local CBOs, in the value

of a CCH in La Plata County. Further discussions with Mercy Hospital, Axis Health System, Animas Surgical Hospital and other local healthcare providers are warranted to evaluate their interest in participating in the formation of a CCH, since the success of the CCH is dependent on screening and referrals from healthcare providers.

Based on community input and feedback, the proposed next step is to develop a business, or “strategic”, plan to establish a roadmap for creating and sustaining a CCH in La Plata County.

The full summary report may be viewed here.