A fundamental question continuing to face the healthcare industry is: How do we comprehensively address the needs of patients when those needs extend beyond the boundaries of traditional clinical care? At PCCI, we have been focusing on this very challenge since 2012. And, while there has been much talk and excitement about social determinants of health (SDOH), we believe that the majority of health systems still don’t leverage social/economic information when designing population health programs, developing patient-specific treatment plans, locating new services, or conducting community needs assessments. Now is the time for that to change because: (1) it is essential for ensuring the best outcomes, and (2) the COVID-19 pandemic has further exposed gaps in our care delivery models and the importance of addressing the needs of the whole person, especially for our most vulnerable populations.
At PCCI, we have developed a framework called Connected Communities of Care (or CCC) to describe a local ecosystem comprised of health systems, payers, community-based organizations (CBO), philanthropic organizations and local municipality officials to coordinate services that span the clinical-to-non-clinical continuum. Entities leverage a CCC-appropriate digital platform and collectively manage end-to-end workflows centered around the needs of an individual to address his/her SDOH. The aim of a CCC is to improve the health, safety and well-being of a community’s most vulnerable residents, and do this in a coordinated, cost effective and sustainable manner.
Having a well-established CCC in place in Dallas is impactful during ‘normal times’ and, importantly, it has allowed us to be more nimbler in our clinical and community-based responses to COVID-19. Three essential COVID-19 activities were possible because of CCC and the corresponding data infrastructure include:
- Neighborhood Prioritization – By Wworking with CBOs, local government leaders, and several large health systems in the Dallas metroplex, PCCI has been able to use the Dallas CCC to quickly assemble data to help identify hotspot neighborhood locations where the virus is having a disproportional impact on the residents, many of whom are poor and underserved.,Aand then turn that information into targeted communications and tactical strategies to improve containment efforts through community-wide awareness and education messaging.
- Expediting Data Sharing. By connecting local CBOs and faith-based organizations with public health workers and clinicians, we have been able to facilitate effective contact tracing and implement care plans for high-risk individuals in a more efficient and scalable manner.
- Streamlined Communication – The value of the CCC communication network linking healthcare providers and CBOs cannot be underestimated. I, as it represents a highly effective and efficient mechanism to disseminate leading practice information aimed directly at the high-risk populations. We have seen first-hand that communications delivered to community residents through familiar food pantries, homeless shelters, and places of worship are much more effective than community-wide public information campaigns broadcast via radio or television. Similarly, targeted messaging aimed at specific community residents who have tested positive for COVID-19 or are living in close proximity to another individual previously diagnosed with COVID-19 is much more effective when communicated via CBOs. This increased effectiveness is based on the fact that many of these at-risk individuals frequently visit the CBOs on a regular basis for essential services and these individuals know and trust the CBO staff delivering the information.
The Power of a CCC
Building or participating in a CCC should be a strategic imperative for most, if not all care providers. We’ve written a playbook to inform organizations on needed steps for the initial building/deployment as well as the long term sustainability of a CCC. Through our experience in Dallas, we have learned that:
- Deployment is multi-factorial – people, process and technology (6 tracks of activity are needed) and most often, the public health department needs to be part of the CCC.
- Engagement is complex – new, diverse orgs are involved, many of which are small, volunteer-based enterprises. All are currently challenged for the need to do work virtually and are actively managing staff shortages – especially for those who rely on volunteers.
- Technology and data are essential – CCC’s need to be able to integrate and manage PHI, not just SDOH. Governance for data decisions, data use rights and data sharing and workflow integrations are critical at the outset and for lasting success.
Let your journey begin, and please contact me if PCCI can provide assistance as you embark upon or refine your approach to Connected Communities of Care.