What if a health care organization decided that in every patient-staff encounter, the relationship with the patient was as important as high-quality medical care? What if the measure of a strong care team was not just knowledgeable medical staff, but also staff with lived expertise who excelled at connecting with patients? What if a health system prioritized trusting relationships and partnerships with the communities they serve as much as they focused on profit and productivity?
Through Advancing Integrated Models (AIM), supported by the Robert Wood Johnson Foundation and led by the Center for Health Care Strategies, we assisted eight health care pilot sites in supporting integrated and person-centered care for people with complex health and social needs. The pilots took many guises, from integrating community health workers into care teams, to overhauling a care management system to ease navigation for providers and patients, to redesigning how pediatric care was delivered with input from families. And we used many names for the work — trauma-informed care, anti-racist care, care to address health-related social needs. Despite the many variations, a consistent theme emerged across all of the pilots — prioritizing relationships was the driving force behind transformation. It was the “secret sauce” enabling culture change.
Strategies for Intentionally Prioritizing a Focus on Relationships
Valuing relationships at both the patient and staff level and the organizational and community level can be a powerful health system strategy to establish a more person-centered, trauma-informed, and trustworthy culture. Committing to relationship-centered care builds deeper engagement with patients, helps support care that is reflective of the needs and wishes of the communities being served, and promotes inclusivity and health equity. Through AIM, we clearly saw that relationship-centered care is not something that just “happens,” rather organizations have to intentionally focus on building and maintaining connections.
Here are key takeaways and examples from the AIM pilot sites to help inform health care organizations interested in strengthening relationships with patients and community members.
1. Invest in training and give staff language to help them build relationships.
When an organization commits to prioritizing relationships with patients and the communities it serves, staff at all levels can benefit from training on how to best communicate. This is especially true as organizations expand beyond medical care to also address health-related social needs.
At Maimonides Medical Center in Brooklyn, New York, community navigator staff developed a customized screening tool that puts patients’ wants and needs at the forefront, and provided staff with guided conversation prompts to help strengthen patient connections. Scripts were provided for staff with examples of language to conduct medical and social needs screening in a way that engaged empathetic communication with each person. Following the customized screening, patients are connected to community-based programs assisting with needs like housing, food security, transportation, care coordination, benefits, and more. At Stephen and Sandra Sheller 11th Street Family Health Services in Philadelphia, staff begin patient screening calls by acknowledging that they will be asking about housing or food needs. Realizing that these types of questions can feel personal or even threatening, the staff assure patients that they do not need to answer if they do not want to and the sole reason for asking these questions is to help support their needs. They find this approach helps reduce fear and stigma for patients, making it easier for staff to gather information and helping patients access the care and services they needed.
2. Design your care model with feedback from the people and communities you serve.
If health systems want to increase trust and engagement, they need to solicit input and feedback on how care is designed and delivered from the people being served. This includes understanding what patients and communities feel is important for the health system to focus on and communicating with patients in ways that feel respectful (and not simply transactional).
At Boston Medical Center’s Pediatric Practice of the Future, the staff used human-centered design principles to gather input from families about what they wanted their pediatric care to look like to design the Center’s new care model. The pilot resulted in a new approach to care where social workers reach out to patients before visits and identify any behavioral health or social service needs for the child and family before the child comes in for their medical visit. The 11th Street Health Center surveyed patients about how they’d like to be informed about clinic programs – via text, phone call, or letter ─ signaling respect for patients and families and prioritizing the connection with them over “pushing” a program on them that they may or may not have wanted. Staff at Bread for the City in Washington DC, which includes a food pantry in their FQHC model, surveyed patients and clients about how they preferred to get food by visiting the clinic or through a food delivery program. The program then tailored their approach based on client feedback.
3. Understand that relationship building can — and does — happen at all levels of the organization and invest in it.
Everyone who works in a health system, not just clinical staff, can play a role in shifting culture from one that can feel transactional, to one that feels centered around caring and connection.
As is common practice among organizations committed to trauma-informed care, Hill Country Health and Wellness Center in Northern California trained all its staff in trauma-informed practice, including the front desk and maintenance staff. This organization-wide approach follows trauma-informed care principles where everyone who the patient encounters reflects the trauma-informed values of the organization. Hill Country’s training stressed core principles such as not retraumatizing patients in the clinic who may have a history of trauma and building trust with them. And at Denver Health in Colorado, they set a goal to become a healing organization with a relationship-centered focus. The health system provided trauma-informed training at every level of the organization, including for C-suite leaders.
4. Incorporate staff on care teams whose expertise is building relationships, such as community health workers.
Once an organization prioritizes relationships and trust with patients and community members, it becomes obvious that you need members on the care team who excel in doing this.
Johns Hopkins Healthcare in Baltimore, Maryland, integrated community health workers (CHWs) with lived experience in communities where patients reside. Their inclusion on care teams helped deepen engagement with families and the CHWs were able to provide guidance for the team’s medical providers. The CHWs help connect postpartum moms with depression to mental health supports, assist families with children who have asthma to get access to inhalers, and connect children and adolescents with sickle cell disease to behavioral health supports. Boston Medical Center’s Pediatric Practice of the Future integrated community wellness advocates into their care teams. These advocates work to build relationships with patients and families by doing pre-visit planning/calls and connecting them to community resources.
5. Collaborate across disciplines to facilitate relationships and align payment models to support the delivery of whole-person equitable care.
To address the behavioral and social drivers of health, health systems need to encourage collaboration across health and social service providers and require alternative payment and data collection strategies.
Johns Hopkins integrated their sickle cell team, bringing physical and behavioral health providers together to review cases and better meet the needs of patients with sickle cell disease. Including behavioral health providers helped the care team better engage and build trust with patients, many of whom often suffer with pain crises and feel stigmatized through the multiple visits they must make to the emergency department for pain management. OneCare Vermont, an all-payer accountable care organization, focused on strengthening their relationship with Medicaid to support better identification of individuals who could benefit from enhanced services and supports. Both OneCare Vermont and Vermont Medicaid report greater alignment on patient goals between the two agencies and they continue to work together to streamline data access and integration to better assess the health-related social needs of their shared patients.
Relationships matter, a lot. The AIM initiative taught us that listening and connecting to patients and most importantly building and maintaining relationships with them is not a nice “extra” thing for care teams to do. Partnering and being in relationships with the community also cannot be an afterthought for health systems if they are committed to health equity. These are foundational principles for organizations that want to lead the way toward more equitable, compassionate, healing health care.