Across the country innovative health care organizations serving individuals with complex health and social needs are increasingly finding value in care models that go beyond the brick and mortar of the health system and into the communities where people live, work, and play. This webinar featured speakers from ThedaCare Health System in Wisconsin and Virginia Commonwealth University Health System (VCU Health) who shared their experiences building effective care models to address social determinants of health (SDOH), developing tools to support community-based care team members, and designing a business case for sustaining complex care models.

Providers, health systems leaders, and other interested stakeholders can replay this 90-minute webinar, made possible by the Robert Wood Johnson Foundation, to learn strategies for refining and sustaining new models of care that extend services into the community for patients with complex health and social needs. The webinar is a product of Transforming Complex Care, a national initiative focused on advancing innovations in complex care.


I. Welcome and Introduction

Speaker: Caitlin Thomas-Henkel, Senior Program Officer, CHCS

Caitlin Thomas-Henkel welcomed participants, discussed the webinar series and its purpose, and introduce the presenters.

II. Strategies for Supporting Outreach Workers for Complex Populations

Speakers: Kim Lewis, Program and Community Outreach Coordinator, Virginia Commonwealth University Health System and Derek DeLia, Director of Health Economics and Health Systems Research, MedStar Health

Kim Lewis discussed how VCU Health refined its care model to meet the needs of complex care patients by employing outreach workers to help people self-manage their care. VCU Health also described the tools they developed that help mitigate workforce burnout and fatigue. Derek DeLia shared data and qualitative findings from VCU Health’s evaluation.

III. Building the Business Case for Community-Based Complex Care Interventions

Speakers: Sandi Groenewold, MD, Expanded Care Team Physician Lead, ThedaCare Health System, Laurie Moore, Project Coordinator, ThedaCare Health System, and Derek DeLia

Sandi Groenewold, MD, introduced ThedaCare’s community paramedicine program, and Laurie Moore discussed how ThedaCare used outcomes data to engage hospital leadership and build a business case for sustaining the program through its accountable care organization. Derek Delia provided data and qualitative findings from ThedaCare’s evaluation.

IV. Q&A Session and Closing Remarks