November 13, 2018 | Newsletter
Every day, health care providers and systems across the nation are testing models to improve care for people struggling with a complex combination of medical, social, and behavioral health needs. Key steps in developing effective complex care management programs include finding ways to consistently identify patients, screen and address for social determinants of health, develop tools to coordinate care across settings, and maximize scarce community resources.
The following resources and profiles represent a sampling of the innovative work going on behind the scenes within complex care, and draw on themes developed through Transforming Complex Care, an initiative led by the Center for Health Care Strategies and supported by the Robert Wood Johnson Foundation.
This technical assistance tool, which summarizes approaches from 10 complex care programs across the country, provides organizations looking to refine or start initiatives for individual with complex needs with examples of eligibility and graduation criteria from innovators in the field.
Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations
This brief examines how complex care programs are addressing social determinants of health (SDOH) for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care, including implementing assessment tools, collecting patient-level information, creating workflows to track and address patient needs; and identifying community resources and tracking referrals.
This webinar — featuring speakers from ThedaCare Health System and Virginia Commonwealth University Health System — focused on building effective care models that address social determinants of health, developing tools that support community-based care team members, and designing a business case for sustaining complex care models.
Addressing Social Determinants of Health: Connecting People with Complex Needs to Community Resources
During this webinar, speakers from AccessHealth Spartanburg and Petaluma Health Center shared strategies for addressing SDOH through screening approaches, innovative technologies that track social service referrals, and development of strong connections with community partners.
These profiles highlight promising approaches that complex care programs are using to better identify and address patients’ unmet needs:
- AccessHealth Spartanburg: Wrap-Around Community Support for South Carolina’s Most Vulnerable Patients – This profile details the work of AccessHealth’s community case managers, who connect Spartanburg County’s uninsured adult population to primary care providers and community services.
- Mountain-Pacific Quality Health Pilot: Closing the Gaps in Rural Complex Care – This profile describes Mountain-Pacific’s ReSource Team, which pairs community health workers and volunteers with technology to connect patients in Montana’s hard-to-reach rural or frontier areas to health care and social services.
- ThedaCare: Leveraging Community Paramedics to Bridge Persistent Gaps in Care – This profile features ThedaCare’s community paramedicine program in Wisconsin, which deploys paramedics to the homes of patients with complex needs to review medications, address social needs, and support patient self-management.
- Virginia Commonwealth University Health System: Beyond the Walls and Into Communities – This profile examines VCU Health’s TakeCCARE program, which uses “hotspotting” and “coldspotting” techniques to identify high-opportunity neighborhoods where outreach workers can help individuals with complex health and social needs.
Find more resources on improving care for individuals with complex medical, social, and behavioral health needs at chcs.org/topics/complex-populations/.