Project Overview

The Behavioral Health and Wellness Program (BHWP) began its work on the Collective Impact for High Public Service Utilizers project in July 2015. Sponsored by the Office of Health Equity at the Colorado Department of Public Health and Environment (CDPHE), the project aims to reduce health inequalities around the greater Denver metropolitan area. Specifically, the project seeks to provide people who are homeless or at-risk of homelessness with support in disease screening, education, and service navigation in relation to four chronic diseases: cancer, diabetes, COPD (and related respiratory conditions), and cardiovascular disease. In addition, this project is designed to collect data regarding the usage of healthcare services among this population, with the long term goal of understanding how such services are utilized and how they may be improved.

Community Partners

In order to accomplish the project’s goals, BHWP has partnered with four community service centers: Metro Community Provider Network (MCPN) in Lakewood, CO and Wheat Ridge, CO; Denver Public Library in Denver, CO; and HOPE in Longmont, CO. Each of these four sites have hired Peer Navigators to conduct direct face-to-face work with clients and to capture valuable client information in the process. These Peer Navigators assist their clients in accessing the services they require, as well as assist with providing general knowledge and support through four primary methods: role modeling, advocacy, services navigation, and education. In addition, BHWP employs a lead Peer Liaison who helps to support the Peer Navigators at the various sites and bridges the gap between BHWP and its partners.

All of the four partner sites operate with a different methodology — both MCPN sites provide low-cost healthcare services to needy clients at numerous locations across the Denver Metro area; HOPE performs street outreach in Longmont and features an evening drop-in center, providing a mix of basic services; and the Central Library branch of the Denver Public Library offers on-site services via scheduled hours and localized outreach efforts.

Learn more about our community partners:
Denver Public Library
Homeless Outreach Providing Encouragement
Metro Community Provider Network (MCPN)

Coalition Partners and Stakeholders
In planning and designing this project, BHWP formed a coalition of invested community partners and stakeholders. This coalition convened on numerous occasions in order to plan, inform, and design the project, as well as provide ongoing assistance, resources, and support. In particular, two key coalition partners — the Metro Denver Homeless Initiative (MDHI) and the Colorado Mental Wellness Network (CMWN) — have been integral in refining the scope of work for the project and continue to be invaluable contributors. This coalition met regularly over the first year of the project and will continue to have quarterly meetings for the duration of the project in order to monitor its progress, address issues, and make improvements along the way.

Learn more about our coalition partners:
Colorado Mental Wellness Network
Metro Denver Homeless Initiative (MDHI)

The Project’s Future
BHWP and its community and coalition partners will continue their work on this project until its completion at the end of June 2018. Throughout the process, BHWP will be collecting data from its community partners regarding the clients who are screened for the four chronic diseases, including basic demographic information, which disease(s) they may have, and whether or not they are referred to a provider for healthcare services. All of these data will be aggregated and analyzed by BHWP, which will in turn report the results to CDPHE for further evaluation and consideration.

Ultimately, the information gathered through this project will help to inform the state of Colorado about how people who are at-risk of homelessness utilize healthcare services. Furthermore, the data will indicate the degree to which this population is afflicted by the aforementioned four chronic diseases and will aim to inform policy and system revisions in order to better serve this population. In its totality, the project will not only provide services to a needy population, but will alleviate misuse of healthcare services and make local healthcare systems more efficient — all for the betterment of Colorado.

For more information about the Collective Impact for High Public Service Utilizers project, please contact BHWP at or by calling 303-724-3713.