Programs serving patients with complex medical, behavioral health, and social needs understand that they need to go beyond the medical model and address the social determinants of health. As the field evolves, some of the major emerging opportunities to improve complex care are becoming clear. CHCS recently conducted a national scan to frame key domains for improving complex care. One important aspect, strengthening and expanding the workforce, is particularly ripe for innovation.

The Transforming Complex Care initiative, led by CHCS and made possible by the Robert Wood Johnson Foundation, is supporting the development of replicable care models for individuals with complex medical and social needs. In particular, the six organizations participating in the demonstration are exploring ways to creatively rethink the complex care workforce. The pilot sites are employing strategies to strengthen their workforce, including: adjusting hiring and management practices; investing in staff wellness and community participation; and thinking creatively about ways to extend care team reach.

1. VCU Health System: Hiring for flexibility and empowering staff to solve problems

The Complex Care Clinic at Virginia Commonwealth University (VCU) Health System hires outreach workers who demonstrate flexible and innovative thinking, and empowers these outreach staff to take control of situations. During the hiring process, VCU assesses potential hires on how they solve problems and adapt to changing situations, looking specifically for creative, nimble thinking. Once hired, outreach workers are given a prepaid debit card and the autonomy to solve problems that can be addressed with a small purchase, such as a quick meal, to help facilitate engagement.

2. AccessHealth Spartanburg: Investing in staff wellness and promoting community participation

AccessHealth Spartanburg (AHS) in South Carolina invests in staff wellness in a number of ways. All requests for paid time off are approved, and patient appointments are not scheduled on Fridays to allow staff time to catch up on administrative tasks, paperwork and connect with colleagues. Three or four Fridays per year are set aside as a staff rejuvenation day, when staff participate in team building and educational programming. Each staff member is also encouraged to volunteer with a community group that has some connection to AHS’ mission, including a broad array of local efforts to address social determinants of health. One nurse care manager, for example, is on the board of a local farmers’ market that brings fresh produce into a neighborhood where many AHS patients live. By encouraging this type of engagement both inside and outside of the clinic walls, AHS is helping to build trust between patients and providers.

3. Mountain-Pacific: Engaging volunteer networks and veterans

Many Montana residents have to travel long distances to access health care — frontier towns can be hundreds of miles away from the nearest primary care and specialty services. Additionally, while other regions may have relatively large numbers of nurses and social workers to support care coordination efforts, Montana’s workforce pool is inherently more limited. Mountain-Pacific Quality Health’s pilot in Montana is addressing this limited pool of providers by engaging two volunteer networks, ASSIST and Keeping You Home, to extend the reach of the care team. ASSIST sends volunteers into patients’ homes and also provides services at a central location, while Keeping You Home uses retirees as volunteers to visit other seniors in need of assistance. In addition, because one in 10 Montanans is a veteran, Mountain-Pacific is in the process of hiring a military veteran to support outreach and engagement efforts.

Accelerating the pace of innovative complex care strategies

These Transforming Complex Care efforts build on emerging opportunities identified through CHCS’ Complex Care Innovation Lab with the goal of identifying replicable and scalable approaches. While pioneering health care stakeholders are using innovative strategies to address patients’ complex needs, some strategies can seem like pipe dreams to organizations that are just starting out or that have limited resources. The innovations detailed above are just a few of the strategies being tested, enhanced, and expanded through the Transforming Complex Care initiative. Stay tuned for future lessons about ways to adapt and replicate program elements in diverse environments. Learn more about the Transforming Complex Care pilot programs in these site profiles.

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