The Metro Denver Partnership for Health (MDPH) is led by the six local public health agencies (LPHAs) serving the seven-county Denver metro area: Boulder County Public Health, Broomfield Public Health Department, Denver Department of Public Health & Environment, Denver Public Health, Jefferson County Public Health, and Tri-County Health Department.

MDPH is a partnership between public health, health systems, human services, and health alliances that has been collaborating since 2014 to improve population health regionally with collective action. MDPH’s work impacts nearly 3 million Coloradans — 60% of the state’s population.

Goals/Objectives

In March 2020, MDPH established eight workgroups comprised of local and statewide public health and health care stakeholders to prepare and respond to their communities’ public health needs during the COVID-19 pandemic. The workgroups were charged with identifying, informing, and implementing collective strategies for mitigating COVID-19.

Workgroup objectives include(d):

1.     Leadership: Discussing urgent issues, engaging with state leadership, writing letters urging policy change, and                        brainstorming opportunities for collaboration.  

2.     Containment: Identifying epidemiology strategies for addressing COVID-19, including strategies for disproportionately              impacted populations.

3.     Monitoring: Increasing collaboration and partnership among regional partners in COVID-19 data sharing and analysis              and increasing support to decision-makers on COVID-related policy recommendations.

4.     Testing: Creating and implementing a process for testing patients who have a health care provider and laying the                    groundwork for community testing for underserved populations.

5.     Immunizations: Identifying and recommending strategies that health care systems, public health, and community                      partners can implement to increase adult and child immunization rates in 2020-21 and prepare for COVID vaccination.

6.     Schools: Supporting schools in implementing public health guidance, clarifying state case and outbreak instructions,                and providing feedback and recommendations to schools and the state health department on how to improve and refine          guidance.

7.     Resource Navigation: Identifying and recommending strategies that public health and community partners can                          implement to support families affected by COVID-19 and promote long-term recovery.

8.     Behavioral Health: Adapting the successful Let’s Talk Colorado anti-stigma mental health campaign to reflect COVID-19          impacts.

MDPH’s success is based on several factors. MDPH’s track record of collaboration created high levels of trust. Throughout the planning and development of its proposals, MDPH ensured alignment with the governor’s office and Colorado Department of Public Health and Environment (CDPHE) by ensuring direct representation and feedback from those agencies. MDPH also has backbone administrative support to stand up and facilitate these activities so public health directors and staff could focus their time on content and response. 

Results/Outcomes

Collaboration increased MDPH’s ability to be successful and act as a unified decision-making voice for our community. We created action plans for mitigation, containment, testing, schools, immunization, and mental health. Much of this work was adopted by CDPHE, and many recommendations were integrated into practice. For example: Mile High United Way lists community testing sites on its website. MDPH’s unified voice and joint actions informed many policy decisions, including regional mask and stay-at-home orders, that ultimately influenced state decisions. MDPH has informed the safe opening/closing of schools.

Statement of problem

Residents of the Denver-metro area live, work, play, and attend school across county lines. COVID-19 response could not be conducted on a county-by-county basis. MDPH used its established regional collaboration to tackle this challenge. MDPH also maximized resources, staff, and expertise across a variety of topics during a time when capacity was limited. Metro area metrics did not always reflect statewide trends or policy decisions - MDPH unilaterally and jointly extended the region’s stay at home order in early May based on the region’s concerning metrics.

Target populations

Segments of Colorado's population have been disproportionately impacted by COVID-19. MDPH’s Containment Workgroup identified strategies for eight priority populations including: People who are unhoused; People who are detained or incarcerated; People in long-term care, assisted living facilities, and supportive living environments such as group homes; Young children and families with young children; Medically vulnerable; New Americans; Colorado Tribes and Tribal Organizations, and; People who work in essential industries who may have dangerous job conditions and low wages and lack adequate protections.

Priority populations are at higher risk of severe illness from COVID-19. They may also be disproportionately impacted by the economic effects of the pandemic, which can affect physical and mental health. Priority populations include people harmed by historical policies such as structural racism.

Strategies for priority populations identified early in the pandemic have been implemented across all MDPH Workgroups and plans. For example, the Immunization Workgroup developed a plan for expanding immunization delivery during COVID-19 that acknowledges these unique needs.  Priority populations were at the center of the plan, which includes recommendations for key partnerships, outlets, and communication tips. MDPH used this approach to set up multiple outreach clinics across the Denver-metro region, expanding access to the flu vaccine to several priority communities. We partnered with groups including the Center for African American Health and business districts to host clinics at their sites. Just one of our partners, Denver Public Health, has already held over 90 outreach clinics compared to about 20 in previous years. The majority of their 3,647 vaccines given were to patients who identified as Hispanic or Latinx (53%), demonstrating our success in reaching our targeted communities.

Innovative practices

MDPH is innovative, using the collective impact model and effective partnership to improve population health. The directors utilized their strong relationships to speak with a unified voice to the governor’s office and CDPHE. This advocacy brought local needs to the forefront. For example, MDPH elevated concerns raised by superintendents on school reopening guidance.

Some strengths of this partnership are connections to community and our ability to respond to challenges when the state could not move as quickly. We learned of resources that were available for testing and bridged relationships with groups such as COVIDCheckColorado and University of Colorado Health to expand COVID-19 testing capabilities to schools and neighborhoods needing additional support. We also partnered with Mile High United Way (MHUW) to collect and share data on testing capacities among health system partners. Now the state collaborates with MHUW to post test site locations on its website so community members can easily find accessible and free sites. We acted as a liaison for the state on these resources and had a greater impact than if we were doing these activities in silos.

Adapting to the emergence of COVID-19

COVID-19 highlighted the need to be nimble in our response and structure. We capitalized on flexible funding from philanthropic funders and donations from partners to call attention to strategies that required timely attention. Building upon our established infrastructure, expertise, and resources allowed us to swiftly respond to new challenges brought by COVID-19.

For example, the Let’s Talk Colorado campaign began as a regional project aimed at reducing the stigma surrounding mental health. In spring 2020, MDPH’s Behavioral Health Workgroup decided to update and re-launch the campaign to coincide with Mental Health Month and the COVID-19 pandemic with funding from health systems and public health partners. Available in both English and Spanish, the Let’s Talk Colorado website features a COVID-19 page addressing the range of challenges Coloradans are experiencing, strategies for understanding and managing what we’re feeling, and resources offering behavioral health support to individuals and families of all ages, ethnicities, orientations, and backgrounds. 

The campaign maintains the core, evidence-informed messages of Let’s Talk that acknowledges that everyone experiences mental health challenges and encourages individuals of all ages and backgrounds to talk with one another about our mental health. It has been modified to reflect the impacts of COVID-19 and the need for safe, interpersonal connection. Since the site’s relaunch, it recorded 14,398 page views and 6,457 new visitors, 4,713,568 impressions generated via paid advertisements, and earned media that reached a local television audience of 694,696 viewers.

Local context

One challenge our communities have experienced through this pandemic is disproportionately high cases of COVID-19 among our Latinx population. Having the resources to stay home throughout the isolation and/or quarantine periods is critical to preventing community spread of COVID-19. Latinx representatives and community members detailed difficulties with being able to successfully follow these guidelines due to multiple factors.

LPHAs statewide had developed processes for identifying and providing resources to cases and contacts in their communities. However, strategies and tactics were deployed locally without a coordinated regional effort. MDPH established a Resource Coordination Workgroup to streamline workflows, identify lessons learned, and use data about resource needs to make local policy decisions. The group has identified the most significant employment-related issues facing Coloradans and developed a request to CDPHE and the Colorado Attorney General’s Office seeking increased employer education; shared best practices and resources, including available funding sources for residents, and worked with community-based organizations to provide services; and created mechanisms to facilitate cross-jurisdictional referrals for resource navigation. 

Evidence

MDPH’s recommendations and proposals are evidence-based and include the most current research and guidelines. Please see the references list at the end of each “Supporting Document” in this proposal and each document listed on our webpage (https://colo.health/MDPH) for an overview of evidence.

Overview of MDPH collaboration efforts

Strong cross-sector collaboration is at the heart of MDPH’s work. Our vision is “Improved health in metro Denver through regional collaboration” and our mission is: “We build partnerships between our agencies and across sectors to increase capacity for achieving our vision.”

We believe that health care, public health, human services, and other partners can have greater reach and impact by working collaboratively and contributing unique skills and strengths. Aligned activities enhance, rather than replace, existing local or internal efforts. Collaboration around shared health priorities, including creating common goals, has greater impact by leveraging the existing priorities of individual partners.

In 2020, we developed a shared multi-sector governance structure that fosters increased transparency, clarity around roles and responsibilities, and accountability, ensuring sustainability of a broad collaboration for many years to come. MDPH used these principles and sound infrastructure to coordinate workgroups in March 2020 to help partners prepare and respond to their communities’ public health needs during the COVID-19 pandemic. 

Planning and implementation process

The goals of our COVID-19 response workgroups are to identify, inform, and implement strategies for mitigating increased spread of disease collectively and regionally. The workgroups are comprised of local and statewide public health and health care stakeholders, including health systems, non-profits, foundations, academia, member-based organization representatives, and staff from state and local governmental departments. We were successful in our COVID-19 response efforts due to the breadth and diversity of voices at the table. We were also able to better reach our community with consistent messaging through alignment and consensus across sectors.

MDPH partners identified a gap and needed workgroup for the COVID-19 response, then invited stakeholders to participate in the planning process. This included developing charters and workplans that described: project mission; goals; activities; deliverables; meeting, decision-making, and group structure; roles and responsibilities, and; communication plans.

Partners were responsible for implementing action plans in their communities. For example, MDPH created community-based and health systems testing guidance documents in spring 2020 when there was no clear guidance available. Health system partners helped create and then adopt the “COVID-19 Community Testing Guidance Document for Health Systems” to set up test sites at their clinics. The “Colorado COVID-19 Community Testing” manual included steps for identifying and executing test sites for populations, neighborhoods, and communities who could use additional resources due to increased risk of exposure or COVID-19 cases. MPDH LPHA staff were active participants in creating this manual and collaborated closely with the state health department to ensure alignment with their test site clinical guidelines. We used this connection to disseminate the manuals across the state and help other LPHAs to create and execute their testing plans.

Collaboration with community stakeholders

In addition to health systems, MDPH workgroups included human services and community-based organizations. We could not make change without partnering with those who know what their communities were experiencing, including community-based organizations, promotoras, and faith-based organizations.

For example, vaccine hesitancy and a reduction in primary care visits were associated with decreasing vaccination rates nationwide, and especially in Colorado. By June 2020, average weekly immunizations in Colorado decreased by 40%. There was a need for a coordinated effort to prevent potential outbreaks while also managing COVID-19. Connections to community organizations helped MDPH engage community ambassadors (trusted and respected leaders) to promote the importance of the flu and COVID-19 vaccine. This ambassador program is currently working with 18 metro-area organizations interested or working on this initiative. MDPH also secured funding to ensure ambassadors are adequately and equitably compensated for their efforts.

 New partnerships

MDPH’s COVID-19 efforts strengthened its relationship with Colorado’s executive branch, CDPHE, regional school superintendents, and the University of Colorado School of Public Health. LPHA directors now meet almost weekly with experts in modeling cases and mobility data; the Communicable Disease Branch Chief and State Epidemiologist on best practices for monitoring the virus; and the governor’s office on policies and procedures affecting our businesses, schools, and community members.

These partnerships helped state and local public health stay aligned on strategies and messages to the community to reduce the potential for confusion in an ever-changing situation. Our relationships aimed to give local public health a voice in the process and help the state better understand unique local needs and concerns. For example, Colorado LPHAs are responsible for leading case investigation and contact tracing efforts. We provided input through MDPH’s Containment Workgroup on what technology and data points were relevant so when the state ultimately purchased its software, it would meet the needs of our staff and community. We are excited to continue our partnerships with these leaders as we address future public health challenges together.

Health equity partnerships

As MDPH began implementing various COVID-19 interventions, every program needed a strong equity focus. The COVID-19 pandemic has disproportionately affected some groups and communities more than others. The existing MDPH Health Equity Workgroup was able to contribute insight and feedback on COVID-19 workplans. Equity Workgroup members reviewed and informed the Containment Workgroup’s Priority Populations plan. The MDPH community ambassador program was structured to ensure it is based in disproportionately affected communities, with the Equity Workgroup identifying a need for a joint meeting with the Immunization Workgroup and CDPHE’s “Champions for Vaccine Equity Initiative” to explore state and local vaccine planning considerations through an equity lens. Health equity and immunization experts provided feedback on COVID-19 vaccine acceptance survey results and equity concerns and considerations on the state’s vaccine delivery plan.

Our goal is to continue involving MDPH’s equity experts throughout all of our programs in 2021, including not just to the COVID-19 workgroups, but to our other existing MDPH teams to build capacity across the partnership.

MDPH’s ability to adapt to emerging needs

MDPH quickly adapted to meet the needs of the community throughout our COVID-19 response. This includes adding workgroups as new needs came up, including for example when schools were reopening or as data on vaccines emerged. We originally started with containment, monitoring and testing strategies and soon realized it was important to modify workplans within the existing workgroups and identify new groups all together as the pandemic changed. Additional staff were onboarded and redeployed to this work throughout the process.

For example, the containment workgroup originally focused on identifying the workforce needed to lead investigation, tracing, and resource navigation efforts in the metro Denver region. As patterns of COVID transmission rapidly revealed health inequities, the workgroup developed a document highlighting unique considerations for supporting priority populations and made recommendations for reducing disparities along a continuum of prevention and mitigation to recovery. These recommendations were grounded in the awareness that systems of oppression such as racism contribute significantly to the disproportionate impacts of COVID-19 and call for local public health agencies to develop a COVID-19 response and recovery plan based on a racial equity lens.

Lessons learned

MDPH had learned much over the past nine months that we can take into our future collaborative efforts.

Prior to COVID-19, MDPH’s LPHA directors were not routinely involved in regional policy. COVID-19 required difficult decisions that needed to be made at the regional level (e.g., stay-at-home orders). We learned that consensus in public health policy decisions increased our likelihood of success and efficacy. MDPH was active in writing op-eds, letters to the editor, and letters to leaders in the state. We want to find opportunities to use our collective voice in the future to ensure an equitable approach to COVID-19 recovery and continued public health and health care needs facing our communities. Speaking collectively as public health and health care  adds value and strength to our efforts.

Organizational structure and governance

Secondly, we learned to be flexible with our organizational structure. In partnership with human services and health system representatives, we reevaluated our governance structure in fall 2020. We updated our process for identifying emerging topics that require focus and for approving new cross-collaborative workgroups. This process will be implemented in 2021 and allow us to address needs quickly.

New funding streams

Finally, we found and secured funding from philanthropic partners who have not historically invested in public health or MDPH. Health systems partners also supported specific workgroup efforts, including behavioral health. We hope to continue demonstrating our value and collaborating with these organizations and foundations to positively impact the health of our community.

Public health impact

MDPH directors have been committed to working together regionally through formal collaboration since 2014. Before COVID-19, MDPH had already seen benefits in sharing resources and approaches, the increased collaboration that comes from relationship development, and the increased ability to leverage the resources. However, the COVID-19 pandemic highlighted the benefits of aligned cross-sector collaboration.

MDPH helped bridge sectors during a confusing and often chaotic time. It provided a space for directors, epidemiologists, clinical staff, emergency preparedness planners, and private funders to discuss and troubleshoot issues. We were able to effectively and efficiently respond to the complex range of needs COVID-19 brought on the metro communities through aligned messaging and action. Our common voice informed policy action to slow the waves of COVID-19 cases and deaths.

Public health can no longer work in silos nor use jurisdictional lines to make decisions. Our communities are affected by the decisions each county makes and MDPH has shown that we can make a greater impact pooling resources, time, and expertise when we work together.