Community care coordination is a hands-on approach to addressing local health needs. It engages residents and leaders, community organizations, and health care workers who have a vested interest in the health and well-being of their community. This collaborative will work together to identify and prioritize key health needs, coordinate existing strengths to develop innovative solutions, and plan projects that continue to ensure everyone has a fair opportunity to be healthy.
Why Use Community Care Coordination?
According to the World Health Organization, "health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." (World Health Organization, 1946) Being healthy means more than just not being sick, our health is impacted by a wide range of non-medical factors. Although clinical care is a contributing factor, it’s also important to emphasize the primary drivers of health outcomes are the conditions in which people are born, grow, live, work, and age – also known as the social drivers of health. Populations frequently need access to other services that go beyond clinical care. Examples include factors such as education, neighborhood and physical environment, employment, and family and social support. Community care coordination challenges health and social service providers to consider the social drivers of health and how these factors hinder an individual, population group, or community’s ability to be healthy, stay healthy, or recover from an illness. It promotes the idea that despite societal factors optimal health should be attained for all people. Through community care coordination, health, and social service providers can support different services that assist with, for example, food access, employment aid, transportation, and housing. They positively impact a person’s long-term health and well-being; also improving community health outcomes.
How Do We Use Community Care Coordination?
The Community Champion and their leadership team are required to participate in a multi-year planning process. This 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 health care organization and its community partners.
Step One focuses on building a comprehensive foundation for positioning the organizations to identify and connect with diverse community partners by establishing a forum for building collaborative partnerships. Services provided include DRCHSD staff facilitating a Community Connect event, followed by facilitating the development and dissemination of a community assessment or questionnaire.
Step Two provides the processes needed to collaborate with community partners to identify and address community and patient health needs by maximizing capacity and available assets to improve transitions of care. Services provided include DRCHSD staff facilitating a Community Priority Action Planning Workshop to identify focus areas for action planning and implementation. Support will also be provided to the Community Champion in facilitating a Community Connect Celebration to highlight progress in improving health outcomes.
Step Three focuses on monitoring progress, strengthening collaboration, and strategizing for ongoing self-sufficiency and sustainability to ensure diverse and vulnerable populations benefit from coordinated care. Services provided include DRCHSD staff and the Community Champion facilitating a Stay the Course Workshop to analyze previous work, determine next steps, and sustain impact.
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.
Tools for Understanding Communities
Meeting a community’s unique health needs isn’t possible without first understanding the current state of health there. This also helps create positive health changes for everyone. The resources below teach the Community Champion how to search through secondary data, help the Community Champion gain knowledge and experience, and provide the Community Champion with an in-depth look into their community's characteristics. These tools lay the groundwork to ensure priorities and activities meet the needs of the community.
Community Health Status Report
Each selected DRCHSD health care organization will be provided a Community Health Status Report upon Community Champion onboarding by DRCHSD Program staff, complete with secondary data about each local county/parish and state. It will include information such as demographics for the county, health behaviors, clinical care, health outcomes, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) responses.
This data should be used to brainstorm potential or acknowledge current community partners for collaboration. Community partners are trusted community leaders, community organizations, and people with lived experience. Their voices are essential to informing the work.
Secondary data will also be used in the community care coordination process to identify and action plan priority areas. This is done with input from each health care organization’s leadership and community partners. Priority area examples may include developing an education program, opening a new clinic, or addressing transportation needs. The determining factor is up to the Community Champion, the health care organization, and community partners – everyone plays a crucial role in changing the health of the community!
Community Champions are encouraged to complete a walking and windshield tour during their onboarding. This is designed to equip the Community Champion with knowledge of their community's characteristics and broaden their perspective of the area residents live, learn, work, play, worship, and age. This can be done either on foot or from a moving vehicle. Community Champions make observations that are essential to inform all phases of community care coordination planning, development, and implementation.
The extent to which employees are passionate about their work and committed to the organization (engagement) and the choice by an employee to stay with an organization instead of seeking employment elsewhere (retention).
