We Know You’ve Heard about Care Coordination – Here’s How to Make it Happen

Care Coordination

The primary objective of human service organizations is to help individuals, families, and communities attain a self-sufficient, healthy and sustainable future. Many organizations, however, struggle with the ongoing challenges of running programs hampered by rapidly changing economic, social structure, demographic, communication, and technology environments. The ability to adapt to this changing environment is key to providing the best possible care.

The Michigan Department of Health and Human Services recognized this need to adapt. Until January 2015 the department of Health and the department of Human Services operated separately and frequently ran into problems as they tried to oversee 140 programs that often had overlapping pieces. State officials choose to combine these departments and create an integrative business model to facilitate collaboration and communication between agencies to improve outcomes for individuals in the state.

Despite the short-term obstacles that have come from combining the two departments, Chief Deputy Director for the Michigan Department of Health and Human Services, Timothy Becker, said “I think overall with the merger, and now we’ve been able to synchronize, we’ve got different administrations talking to each other.”

The Human Services Value Curve

In order to help human service organizations improve their capacity to care for individuals in their communities, Leadership for a Networked World partnered with the Human Services Summit at Harvard University to develop the Human Services Value Curve framework. The goal was to develop innovations which enable organizations to mature and deliver broader and more valuable services to those they serve. The Human Services Value Curve has four levels of business models: Regulative, Collaborative, Integrative, and Generative.

Regulative Business Model

Most organizations find themselves in the regulative level of the Human Services Value Curve. At this level, agencies focus on program-specific compliance and effective delivery of services. Individuals who are eligible receive a specific service that is timely, accurate, and easy to understand. Organizations which stay in this regulative layer, however, remain focused on running efficient programs rather than addressing the needs of the individual. To solve this tendancy it is necessary to take a step back from the day-to-day activities involved with running programs and develop a plan of collaboration between programs and agencies. This takes us to the next level on the Human Services Value Curve: The Collaborative Business Model.

Collaborative Business Model

At the collaborative level, the focus is on working across agency and program boundaries to provide the best combination of services a patient may be eligible for. In essence, an individual can “walk through a single door” and access a complete array of products and services. In order to accomplish this, organizations must work with partners to focus on cross-programmatic effectiveness. For example, the city of Columbus, Georgia is providing supportive housing and wrap-around services with the goal of ending veteran homelessness.

Every other week a representative from all agencies involved meets to review the in-flow of veterans, the number of veterans still waiting for housing, and the number of individuals being housed. The committee then discusses each case and creates a plan to help the individual obtain and maintain stable housing. This information is shared with all participating agencies through a Google Doc that is accessible to everyone. Which takes us to the next level of the Human Services Value Curve: The Integrative Business Model.

Integrative Business Model

At the integrated level, organizations and communities focus on addressing the root causes of individual and family concerns by coordinating and integrating services at an optimum level. In order to ascend to the integrated level, organizations must include technology and data sharing that enables organizations to view all aspects of the patient’s needs and create a custom care plan. The goal is the early detection and intervention of potential problems instead of fixing problems downstream when they have become a crisis. A great example is the Los Angeles County Health Department’s Whole-Person Care pilot program.

The objective of this pilot is to build an integrated health system that delivers coordinated, wrap-around services to 50,000 of the most vulnerable, high-risk individuals living in the county. The pilot brings together 11 human service organizations to provide coordinated services to patients who are homeless or struggling with mental illness or substance abuse disorders. According to Dr. Clemens Hong, Director of Whole-Person Care Los Angeles, “The idea is to have a communitywide network of care with information that’s shared appropriately to help a patient.” Hong continued, “The care coordination platform will provide the technology infrastructure for Whole-Person Care LA and enable our teams to connect the most vulnerable LA County residents to services.”

Generative Business Model

This takes us to the final level of the Human Services Value Curve: The Generative Business Model. The focus of this level is to take the infrastructure built in the integrative level and join forces to co-create solutions for whole communities. This requires targeting community-level infrastructure and cultural presumptions to improve the health and well-being of a whole population.

According to Dr. Antonio Oftelie, Executive Director of Leadership for Networked World and Public Sector Innovation Fellow at the Harvard School of Engineering and Applied Sciences, “Human services are deeply embedded within an ecosystem of public, private, and social sector organizations, which means that innovation has to be aligned across multiple organizational boundaries.” Oftelie continues, “The central challenge for leaders in human services is how to help people across an ecosystem adopt new business models, capabilities, and cultural attributes.” In summary, organizations who advance to the generative level have reached the point where they can influence care for entire communities and populations.

How can you help your specific organization overcome challenges and advance on the Human Services Value Curve? To get started moving up the path, we’ve provided a list of questions to consider:

  • If there were no financial or time limits, what outcomes would we hope to deliver to our clients?
  • How can we think more creatively to deliver those outcomes?
  • What other organizations play a key role in driving these outcomes for our clients?
  • What opportunities exist to engage and collaborate with those agencies?
  • Do we have the right resources and expertise to be able to increase our service capacity?
  • Do we have the right technology in place to support these new initiatives?

It is important to remember that ascending the Human Services Value Curve is a non-linear process. There will always be changing economic forces, social structure, and community demographics at play. The key is to create a policy and technology infrastructure that enables you to quickly adapt and continue to climb. Here are some additional resources to help you on your journey:

APHSA Toolkit: Moving through the Value Curve Stages




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