Addressing Needs Through Community-Based Care Coordination

Every community includes individuals who experience a variety of complex health, behavioral, and social challenges. These individuals face not only poor health outcomes for themselves, they often consume a disproportionate share of emergency and healthcare resources. This high use of resources can often be traced back to unmet needs which then lead to crisis situations. The obvious solution to this problem is to proactively address the needs of these individuals, but doing so is not always so simple. These needs are complex and varied and the diverse services that they require are frequently siloed from one another. This means that providers are often trying to address specific needs of high-risk individuals without the information necessary to focus on the whole person.

To solve this problem, communities across the country are developing value-based, patient-centric programs for community-based care coordination. In these innovative efforts, healthcare professionals and providers, behavioral health specialists, food pantries, employment services, housing services, and other programs work together to break down the walls separating their services. To do this they communicate, share data, and jointly provide patient-centered care that treats people rather than symptoms.

No two communities are exactly the same and so no two approaches to community-based care coordination are identical. We would like to share three examples of programs that are utilizing community-based care coordination to address the needs in their communities.

Alaska State Community Action Program

Alaska’s history with Community Action Programs (CAP) dates back to 1966 when the Alaska State Community Action Program (ASCAP) was developed as a statewide nonprofit organization. The ASCAP addressed the needs of at-risk youth in rural areas by repurposing surplus military equipment to aid rural towns with limited resources. This equipment was used in building facilities for housing and services, providing job skills training, and many other initiatives to improve the lives of rural Alaskans.

In the five decades since its inception, ASCAP has grown to include a variety of different services. They have a Child Development Center which provides year-round childcare and they have also implemented a program to reduce juvenile delinquency and tobacco use. Housing is a main focus with supportive housing being available for individuals experiencing substance abuse, physical disabilities, and mental illness. ASCAP also provides transitional housing for families and children experiencing homelessness.

In 2017, ASCAP provided services for 1,300 children, improved homes for seniors and individuals with disabilities, provided supportive housing for over 700 individuals and found affordable housing for 178. During this time, they also received accreditation for Supportive Housing, Community Development, and Child Development Division programs. Through their coordinated programs, ASCAP is improving the lives of rural Alaskans by giving them the support and opportunities they need to thrive.

Butte Community Diabetes Network

Over 30 million Americans suffer from diabetes. In Butte, Montana the Butte Community Diabetes Network was created to address the needs of diabetes patients in their community. The program, which is led by St. James Healthcare Foundation, provides a variety of resources to help individuals learn to manage their diabetes through lifestyle changes. The available programs include case management, support groups, education and prevention classes, nutrition resources, and weight management programs. They also provide a hotline operator that assists patients in making appointments, obtaining prescriptions, accessing community resources, and communicating with physicians. By giving individuals the resources they need to manage their chronic conditions, the Butte Community Diabetes Network is helping to improve the outcomes of diabetes patients.

San Joaquin County, California

California has a statewide focus on community-based care coordination through the waiver based Whole Person Care (WPC) pilot program. WPC is designed to help counties address the needs of high-risk individuals by focusing on combining resources to treat the whole person instead of using isolated programs to address individual symptoms. These integrated programs combine collaborative leadership, patient-centered care, data sharing, and financial flexibility to coordinate services across diverse providers.

As part of the WPC program, San Joaquin County operates a Whole Person Care Integration team that is responsible for assigning high-risk individuals a care coordinator and developing a care plan that is specific to the unique needs of that individual. The target population for this program is made of up of three overlapping populations, individuals who experience a substance use or mental health disorder, individuals who disproportionately utilize emergency services, and individuals who are at high risk of homelessness as they transition from incarceration or medical facilities. This program operates as a partnership between low-income housing providers, community health providers, medical centers, nonprofit and charitable supportive service providers, substances use services and behavioral health services. The final goal of this program is to provide individuals the resources that they need to ultimately transition to a more independent care system. In the fall of 2018, there were over 300 individuals enrolled in the San Joaquin County program.

Community-based care coordination is an essential tool in addressing the needs and improving the outcomes of high-risk individuals. But just as no two communities are the same, no two programs function exactly alike. The key is to create a data-sharing infrastructure that enables communities to use evidence-based interventions to improve the overall wellbeing of their communities.

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