Building Connected Communities of Care

The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations

Keith Kosel, Steve Miff, Keith Kosel, Steve Miff

• Publisher: Productivity Press
• Year: 2020
• ISBN:
  9781000037074
• Edition: 1
• Topic: Medizin
• Subtopic: Gesundheitswesen, Verwaltung & Pflege

As a community, aligning efforts across a community to support the safety and well-being of vulnerable and underserved individuals is extraordinarily difficult. These individuals suffer disproportionally from health issues, job loss, a lack of stable housing, high utility costs, substance abuse, and homelessness. In addition to medical care, these individuals often critically need access to community social sector organizations that provide a distinct and complementary set of services, such as housing, food services, emergency utility assistance, and employment assistance. These services are just as vital as healthcare services to these individuals' long-term health and well-being, with data suggesting that 80–90% of health outcomes can be attributed to factors beyond direct medical intervention.

This book proposes a novel approach to the coordination of medicine and social services through the use of people, process, and technology, with the goal being to streamline coordination between medical and Community-Based Organizations and to promote true cross-sector patient and client advocacy. The book is based on the experience of Dallas, TX, which was one of the first metropolitan regions to develop a comprehensive foundation for partnership between a community's clinical and social sectors using web-based information exchange. In the 5 years since the initial launch, the authors have been able to provide seamless connection, communication, and coordination between healthcare providers and a wide array of community-based social service organizations (a/k/a Community-Based Organizations or CBOs), criminal justice entities, and various other community organizations, including non-collegiate educational systems.

This practical how-to guide is the codification of transferrable lessons from successes and challenges faced when working with clinical, community, and government leaders. By reading this playbook, leaders interested in building (or expanding) connected clinical-community services will learn how to: 1) facilitate cross-sector care coordination; 2) enable community care partners to better provide targeted services to community residents; 3) reduce duplication of services across partnering organizations; and 4) help to bridge service gaps in the currently fragmented system. Implementation of services, as recommended in this book, will ultimately streamline assistance efforts, reduce repeat crises and emergency funding requests, help address disparities of care, and improve the health, safety, and well-being of the most vulnerable community residents.

Chapter 1

Playbook Overview

A Connected Communities of Care (CCC) is designed to accomplish the critical alignment of providers and Community-Based Social Service Organizations aka Community-Based Organizations (CBOs) to support the safety and well-being of vulnerable and underserved community residents. These individuals suffer disproportionally from poor health, job loss, a lack of stable housing, high utility costs, substance abuse, and homelessness. In addition to medical care, these individuals typically need access to CBOs that provide a distinct and complementary set of services, such as housing, food services, emergency utility assistance, and employment assistance. These services are just as vital as healthcare services to an individual’s long-term health and well-being.

A CCC serves as a comprehensive foundation for this partnership between a community’s clinical and social sectors. It typically leverages a cloud-based information exchange/case management software platform providing seamless connection, communication, and coordination between healthcare providers and a wide array of CBOs and other entities, such as criminal justice entities or educational systems. The software platform enables bidirectional communication, referrals, service, and program tracking and offers a continually updated inventory of clinicians and CBOs. Through a CCC platform, a community can establish—and leverage—a wide variety (both in size and in region) of community partnerships, serving any type of population, to ensure the right type of assistance, adequate program enrollment, limited program dropout, and successful program implementation.

Among the key drivers of success of a Connected Community of Care is a sustainable technology infrastructure that supports information sharing among the providers and other community partners. The Parkland Center for Clinical Innovation (PCCI) CCC is powered by Pieces Iris^® software, licensed through Pieces Technologies, Inc. Similar to an Electronic Health Record (EHR), the software and associated applications capture, securely store, and appropriately provide access to vital information about individuals and service organization clients in a way that supports the unique, underlying workflows. If all participating organizations on the CCC platform are using the software, then they all are connected through the secure, closed-loop referral system and are thus able to communicate and share information with each other. For organizations on a different platform, the software offers connectivity through industry-standard, data connectivity methods. PCCI’s CCC not only connects CBOs via a secure, state-of-the-art, two-way messaging platform but also wraps around the technology a wealth of field-proven and leading clinical and CBO workflows to make services and coordination of community populations more effective and cost-efficient.

A CCC facilitates the secure exchange of critical case management information at various steps in the process, such as when an individual first seeks food assistance or requests emergency housing. It lays the groundwork for an innovative system of assistance and broader social service delivery and creates a longitudinal perspective of care via referral tracking and access to a broad array of services to improve individual well-being and community health. Ultimately, a CCC streamlines assistance efforts; reduces repeat crises and emergency funding requests; helps address disparities of care; and improves the health, safety, and well-being of the most vulnerable community residents.

Playbook Purpose

PCCI’s CCC Playbook provides a tactical guide to enable organizations to succeed in designing, deploying, maintaining, and sustaining a CCC in a community. The approach to success is described in this Playbook through the following key elements:

• Detailed description of the six core Tracks orchestrating CCC design and implementation
• Key roles and responsibilities
• Requirements (and associated Milestones) to successfully complete each Track
• Strategies for success and overcoming challenges
• Case studies and practice pointers highlighting PCCI lessons learned
• Workflows/processes
• CCC measurements of success
• Key sample documents for successful CCC design and implementation

Guide to Playbook Terminology

This terminology guide defines the common words and phrases PCCI uses throughout this Playbook:

• “Track” is a primary pathway supporting a CCC’s design, implementation, and ongoing operations.
• “Requirement” is an essential element that should be completed within each Track. Although the Requirements are numbered sequentially, based on PCCI’s experience, the actual timing of the work across Requirements may vary or occur in parallel with work in other Requirements or even work across other Tracks.
• “Milestone” is a waypost measuring the progress of the work conducted in a specific Requirement towards the ultimate goal. Although the Milestones are numbered sequentially based on the typical progress towards goal attainment, it is possible that certain Milestones may be completed in parallel with other Milestones within a Requirement or even across Requirements.
• “Practice Pointer” is a PCCI example strategy in overcoming challenges to successful CCC implementation.
• “Key Task” is an essential activity (in no specific sequential order) to be performed in achieving Milestones.

The Six Tracks for CCC Implementation

Figure 1.1 illustrates the CCC ecosystem made up of six core Tracks. Development activities and level of model sophistication/complexity flow from the center of the figure outward; each concentric circle represents a core component and development stage of the CCC.

Figure 1.1 PCCI’s CCC Model.

Governance and Legal/Policy are at the core of the CCC as these are essential, foundational components of the work covered in every Track. While PCCI recommends that CCC leaders pursue the Tracks in the following general order, much of the work in various Tracks can (and should) be performed in parallel with work in other Tracks.

Key roles and responsibilities across all Tracks are described in the next section, “CCC Roles and Responsibilities”. PCCI recommends that the CCC leaders assign a designated Track lead for each specific Track. The work in the six CCC Tracks will also require input from additional stakeholders specific to the implementation of that particular Track. The six Playbook Tracks are as follows:

1. Governance Track. A CCC’s governance structure relies on a collective decision-making model rather than on leadership by a specific individual or organization. This Playbook assumes that a few key community organizations have already formed an initial steering group to make the significant decision to undertake the CCC initiative. It is critical, at least initially, for an empowered, established group of decision makers to provide leadership through a “readiness assessment” process and during the initial CCC design stages. The “readiness assessment” comprises a set of activities designed to collectively uncover a community’s clinical and social needs and level of preparedness and commitment to hosting a CCC. See Chapter 2 The Readiness Assessment.
   These key decision makers should initially include Anchors, Partners, Sponsors, or Funders (defined in the “CCC Roles and Responsibilities” section). As the CCC evolves, the governance entity can (and should) expand to include the perspectives of a wider group of community participants. Formal establishment of a governance entity (e.g., a Board) can take place at any point in the process but likely oc...