Mile high specialty care network

The Mile High Specialty Care Network is a matchmaker among primary care and specialty care physicians to meet the growing specialty care waiting lists for Medicaid patients who need it in order to participate fully in work, school, and community.

One-in-three Denver residents are insured through Medicaid, but there aren’t anywhere near enough physician specialists who will accept these patients. In just one year, one safety net clinic alone came up 50,000 specialty care referrals short –patients who didn’t get the care they urgently needed, even though they had insurance.

  • Takes burden off doctor’s offices because MHHA takes over as point of contact
  • Balances demand/track and assign appointments in real time
  • Increases overall capacity/availability of appointments

If every specialist saw only two Medicaid patients per month, we would solve the problem of Denver residents going without care, impacting our community and economy.

Selected to be part of a new Kaiser Permanente ASCENT (Access to Specialty Care Engagement Network) cohort of organizations tackling this problem, the Mile High Specialty Care Network will design a system to connect specialty care programs in most of the Front Range and central mountain region, including virtual and technological solutions like e-consults or online referral networks. To find out more, please contact Vicente Cardona at and/or (720) 370-8166.


In line with Colorado’s State Innovation Model (SIM) grant, which seeks to increase the proliferation of integrated care models in Colorado, the Group plans to provide Denver’s safety-net clinics with education and assistance in implementing integrated care models. MHHA’s regional health connector provides primary care practices with education on substance misuse, depression and blood pressure – and then gives them the tools and contacts so they can provide their patients with any housing, human or social services they might need to maintain good health.


The High Needs Patients Working Group encourages more patients into primary care medical homes to provide appropriate and affordable preventive care to those with chronic conditions, avoiding frequent misuse of emergency departments and expensive hospital re-admittance. An outgrowth of hosting the Caring for High Utilizers Summit for metro-area stakeholders, the group has developed a process to share data between high utilizer programs in Denver, track specific high needs patients and develop a more formal learning collaborative about high needs patients. The group has identified 30 patients to focus on and are developing interventions to make an impact, like setting up medical screening at food pantries to identify at-risk individuals and refer them to appropriate care.

Emerging Issues

Tracking Immigrant Health. After MHHA members noticed an abrupt decrease in people from the immigrant and refugee communities accessing care at their clinics, we surveyed them and found an average 20% drop-off. These clearly are people now going without needed health care. Now we’re convening small groups of people from those communities to explore the problem and develop solutions for our members to implement

Ensuring Safe & Healthy Housing. Recognizing that patients’ health suffers when they’re living in unsafe housing, MHHA brought together healthcare providers and legal experts to plan a pilot program to screen patients at several clinics for housing insecurity and safety problems. Made up of Denver Public Health, Denver Health and Hospitals clinics, DU Student Law School Clinic, Colorado Poverty Law Center and Colorado Legal Services is an intentional effort to improve housing conditions and prevent unfair evictions so patients can achieve and maintain better health. In the pilot’s first three months, the legal-health partnership screened 160 individuals in the first three months – and made 12 referrals to legal help to ensure safe housing