# Data Analytics to Support the Alignment of High Risk Adult Programs & Services

> **NIH AHRQ R18** · DENVER HEALTH AND HOSPITAL AUTHORITY · 2021 · $621,675

## Abstract

High-risk individuals with substance use disorder (SUD), especially those who are justice-involved or
homeless, have poor outcomes across a range of health indicators, including mortality. Better care
requires multiple entities working in concert to share time-sensitive information, identify and prioritize
the highest risk persons, and coordinate care across sectors. We propose to build and test a replicable,
extensible and evaluable clinical support and analytics solution that meets the following specific aims:
SA 1: Establish project scope and governance for data integration across sectors
SA1.1 Convene stakeholders to design shared tools to improve outcomes
SA1.2 Leverage existing governance structures to ensure extensibility and alignment with broad
 community/clinical data-sharing efforts
SA 2: Create a shared language and systematic approach to risk assessment, care coordination
 and monitoring cross-sector use of services and costs
SA2.1 Partner with stakeholders, including patients, to identify information needs
SA2.2 Employ human-centered design principles and Lean methods for tool/dashboard design
SA2.3 Elaborate requirements for EHR-supported workflows/dashboards
SA2.4 Design and build EHR accessible tools for sharing data with capacity to integrate with a
 community-wide, social health information exchange
SA 3: Deploy tools across sectors and assess impact on risk assessment, care coordination
 and performance monitoring workflows
SA 3.1 Use formative evaluation to gauge adoption, reach and extensibility
SA 3.2 Demonstrate the feasibility of summative evaluation to measure ROI
SA 4: Provide a road map for sustaining and extending EHR tool implementation
SA4.1 Partner with Colorado stakeholders to design next phase efforts
SA4.2 Provide a tool kit of extensibility recommendations for state-wide interoperable cross-sector care
 coordination, leveraging data-sharing resources
We will meet these aims and optimize data integration within a common EHR platform (i.e., Epic)
through a Denver-based collaboration that includes an integrated delivery system, EHR-agnostic health
information exchange, a unit that combines local public health functions with advanced informatics, and
homeless services provider.

## Key facts

- **NIH application ID:** 10252817
- **Project number:** 5R18HS027389-03
- **Recipient organization:** DENVER HEALTH AND HOSPITAL AUTHORITY
- **Principal Investigator:** RACHEL EVERHART
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2021
- **Award amount:** $621,675
- **Award type:** 5
- **Project period:** 2019-09-30 → 2023-09-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10252817

## Citation

> US National Institutes of Health, RePORTER application 10252817, Data Analytics to Support the Alignment of High Risk Adult Programs & Services (5R18HS027389-03). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10252817. Licensed CC0.

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