Across the country health and human service providers are joining forces to create networks called health or medical neighborhoods. These health neighborhoods provide the infrastructure, systems, and processes that link an array of providers such as health, mental health and substance use disorder into a tightly coordinated team to provide whole-person care coordination for all patients in the neighborhood. In addition, these health providers are linked to a network of community support providers including housing services, faith-based organizations, job training, and child and family services which address the social determinants of health.
Through comprehensive community care coordination, health neighborhoods hope to eliminate silo-ed and fragmented care and achieve the triple aim: improve patient experience, improve patient outcomes, and reduce per capita cost of care. A high-functioning health neighborhood:
- Ensures effective communication, coordination, and integration with other providers
- Ensures the efficient flow of patient data
- Supports enhanced access and patient-centered, high-quality care
- Improves patient outcomes
- Delivers evidence-based care and improved population health
The Agency for Healthcare Research and Quality (AHRQ) states that “revitalizing the nation’s primary care system is foundational to achieving high-quality, accessible, efficient healthcare for all Americans.” This revitalization involves the ongoing development of an organization’s care coordination culture and a comprehensive, system-level transformation to ensure the delivery of seamless, integrated care. For those communities interested in starting a health neighborhood, AHRQ has provided a list of performance measures that are critical for success:
- Meaningful use of health IT – This provides evidence that neighborhood providers have the capacity for enhanced communication and access to patient information
- Care coordination agreements between clinicians – This provides evidence that providers are aware of their neighbors and have jointly developed proactive approaches for sharing information and care responsibilities
- Development and implementation of longitudinal care plans – This offers evidence that providers are developing care plans for patients and are communicating with other providers
- Duplication of services – Indicates the extent that providers can share existing lab and imaging results
- Provision of unnecessary/efficient services – Provides evidence that providers share all relevant health information to avoid unnecessary services
- Rates of hospitalizations and readmissions – High functional health neighborhoods with improved care coordination should achieve lower rates of preventable hospitalizations and readmissions
Self-Assessment Tools to Get Started
Creating a health neighborhood requires the integration of health, behavioral health, substance abuse, and community providers. Working towards integration is often most successful by simply finding the best next step that the organization and its partners can take. To help organizations and communities get started, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Integrated Health Solutions provided an in-depth, agency-level review comprised of 4 major self-assessment tools:
Tool 1: Partnership Checklist
The Partnership Checklist is a group discussion guide designed to assist organizations in determining the need for a partner, assessing a partner’s potential contribution to the partnership, and identifying next steps for how to develop more effective partnerships. Organizations using the partnership checklist will be able to:
- Identify if they need a partner to pursue integration
- Examine core elements in selecting a potential partner
- Identify their strengths and weaknesses in a partnership
- Identify potential partners for integration
Tool 2: The Executive Walkthrough
The Executive Walkthrough helps the leadership team view the organization through the eyes of the customer. It assesses customer service levels achieved using objective data and lays out a path for improving “customer experience.” The goal of this tool is to help your organization accomplish the following:
- Customer-centered service orientation within the delivery process
- Customers who are viewed as essential partners in the change process
- Customer experiences that are welcoming, efficient, and effective
Tool 3: The Administrative Readiness Tool (ART) for Primary and Behavioral Health Integration
The Administrative Readiness Tool (ART) for Primary Health/Behavioral Health Integration assesses the core administrative processes and practices needed to support the successful delivery of integrated care. Here are some of the questions from ART that determine your organization’s readiness for being part of a health neighborhood:
- Do you have timely and cost-effective access to the treatment process?
- Do you have a centralized electronic schedule management system?
- Have you implemented a caseload management system to support appropriate utilization levels?
- Do you have an outcome assessment capacity and measurement tool to integrate achieved outcomes into support service delivery process change?
Tool 4: The COMPASS – Primary Health and Behavioral Health
The COMPASS–Primary Health and Behavioral Health™ (COMPASS-PH/PC) is a continuous quality improvement tool for clinics and treatment programs, whether working in their own integration process or in partnership with others, to develop core integrated capabilities able to meet the needs of service populations with physical and behavioral health issues. The COMPASS gives organizations the tools to:
- Create step-by-step goals to provide integrated care for individuals and families with complex needs
- Communicate a common language and understanding of integrated primary health and behavioral health capable services
- Establish an organizational baseline of integrated primary health and behavioral health capability underscoring a rational foundation for a change process
- Create a shared process using a common tool that can be used in any system for an array of diverse programs working in partnership on integrated primary health and behavioral health capability development
- Produce a universal, continuous quality improvement framework for all types of programs in any system of care that serves individuals and families with complex lives
In conclusion, a health neighborhood that addresses the social determinants of health while integrating primary and behavioral care is a driving force for delivering high-quality, whole-person care. By working together, organizations within the health neighborhood can determine their readiness for integration and determine the key performance indicators for measuring the success of their efforts. Collaboration between providers, innovation in payment models, and integration of technology platforms are all essential for the health neighborhood to succeed.