Healthy Harbors: An innovative medical home collaboration between primary care, accountable care, and child protective services to reduce health disparities for children impacted by child abuse/neglect

Healthy Harbors is an innovative program providing integrated care to children impacted by child abuse and neglect in a comprehensive, patient-centered medical home.  These children experience health and mental health comorbidities more than any other group of children.   Historically, these health conditions have been under-identified and under-treated due to poor access to continuous medical care and medical homes. Healthy Harbors assists caregivers with complex care coordination of physical, mental, dental, and developmental care. Because of the program’s integration with the Accountable Care Organization, this care continues into adulthood as needed.

Across the nation, child protection services are evolving with recognition that biological family relationships are imperative to healthy outcomes for children.  As a result, Healthy Harbors works with both foster families, and biological and kinship families in which child protection concerns have arisen. We work with children across placements, and throughout their infancy, childhood and young adulthood. Because poverty, substance abuse and mental health issues impact these children and families across generations, our medical home model addresses the social determinants of health through intensive and holistic case management.

To develop a program that could significantly impact the extensive needs of these children and families, as well as sustain long-term changes, we developed a multi-agency oversight group that envisioned, planned, and now guides Healthy Harbors. Active members of the oversight group includes representatives from the two primary care centers it serves, the region’s Accountable Care Organization, the county child protective system, the health department, the mental health center, dental providers, and University of Colorado Health (the regional health system).The group works together to at both an administrative level, and at a day-to-day level to ensure access to community resources and comprehensive health care.

Healthy Harbors is a model program that reduces duplication of services, improves communication among families, providers and agencies, and ensures access to appropriate, ongoing care.  During our session, we will discuss challenges and lessons.  We will share data that includes Medicaid claims and program outcomes.  We will present case samples that highlight the need for multi-agency collaborations to address health disparities.  Participants will be provided with a toolkit to bring back to their community to support their planning efforts. We will demonstrate how a model navigation program for high risk children and adolescents can address and overcome health inequities and significantly impact public health.