Community Care Coordination (CCC)

The DRCHSD Program provides Community Care Coordination (CCC) strategies/planning to each participating organization. CCC planning provides a mechanism to help transform the local health care delivery system and supports the development of an infrastructure for preparing to manage the health of a population. Through CCC planning, providers and other partners can align local services with community needs to improve health outcomes and address social determinants of health (SDOH).

Each participating organization will appoint a Community Champion (CC). The CC will take the lead in implementing the CCC strategies in the community with the support and guidance of the health care organization leadership and DRCHSD Program staff.

The CCC 3-year process is designed to establish a comprehensive foundation to enhance care coordination efforts by leveraging partnerships between providers and community partners. It is a stepwise approach that provides a tactical guide to planning, developing, implementing, and sustaining collaborative outcomes between the healthcare organization and community joint partners.

Step 1 focuses on building a comprehensive foundation for positioning the organizations to identify and connect with diverse community joint partners by establishing a forum for building collaborative partnerships. Services provided include The Center facilitating a Community Connect event and the option of a community assessment or questionnaire.

Step 2 provides the process needed to collaborate with community joint partners to identify and address community and patient health needs by maximizing capacity and available assets to improve transitions of care. Services provided include The Center facilitating a Community Priority Planning Workshop to identify focus areas for action planning and implementation. Support will also be provided to the Champion in facilitating a Community Connect Celebration to highlight progress in improving health outcomes.

Step 3 focuses on monitoring progress, strengthening collaboration, and strategizing for ongoing self-sufficiency and sustainability to ensure diverse and vulnerable populations benefit for coordinated care. Services provided include The Center facilitating a Community Joint Partner Assessment Workshop to evaluate the collaboration's effectiveness and utility beyond the Program. A second workshop will follow to prioritize areas to sustain progress.

This approach builds and strengthens a community's capacity, creates partnership buy-in, establishes accountability and assists the collaborative with creating a plan for sustainability.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $10,000,000 with 100% funded by HRSA/HHS and $0 amount and 0% funded by non-government sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by HRSA/HHS, or the U.S. Government.