And in Seattle’s Chinatown, International District BUILD Health partners coordinated a series of community meetings to better understand barriers to health and wellbeing in the neighborhood. Safety and crime were identified as major sources of chronic stress and sedentary behaviors, especially after last year’s murder of a community leader. The BUILD Health partners spearheaded a survey to inform the development of recommendations to the City for improved neighborhood safety, making direct links between safety and community health. Those are among numerous examples of the kinds of work being taken on in the BUILD communities right now.
What should the CIOs and CMIOs of patient care organizations be thinking about right now, as they and their colleagues consider participating in such community-oriented initiatives?
You bring up an excellent point. The community health needs assessment gives you an excellent direction, in terms of, say, nutritional support. Then you need to identify patients. So we’re seeing a lot of interest in collecting those non-clinical data points during patient interaction. Can clinical leaders support those in standard risk assessments and intake forms, for more individualized information, to refer folks to those community resources or customize their care plan, so we can address those care needs?
What types of functional roles are involved in collecting the data in patient care organizations? Health coaches, nutritionists, etc.?
Anyone who is engaging heavily in risk-based contracting has these potential capabilities. There tends to be a dividing point between the earlier-phase organizations focused only on high-risk patients, and others that are more progressive and who are approaching the rising-risk patients. They’re starting to get more progressive in terms of roles. It can be community health workers, sometimes social workers, dieticians. So it requires proper resource allocation, and it depends on how they organize and deploy those resources. And medical assistants can do it, too, I would underscore that.
How well are the handoffs going to those people?
In physician practices, the handoffs are being conducted quite nicely. Sometimes, it’s a “warm” handoff, meaning that you’re literally walking someone down the hallway. Others have created pop-ups and alerts in the workflow to stimulate handoffs. And there’s a new and emerging role around the community resource specialist. That’s a final link the chain. What’s needed is a high school-educated person, deeply embedded in the community, and connects patients directly to community-based organizations. These individuals are paid by the health system, they’re part of the multidisciplinary team that includes doctors, nurses, Mas, medical directors. Mass General is the organization we’ve profiled.
What will happen in the next couple of years, in all this?
I think that the role of community partnerships will be even more critical than ever, because of the role that social determinants play in total cost and quality outcomes. So if we have to trickle down to reach those social determinants, partnerships are the only way to accomplish that.
Do you have any explicit advice, particularly for our audience?
I would say, recognizing that fundamentally, people don’t want to be patients. So if we want to get into their sphere of activities and be a partner in their health, especially at financial risk, it’s critical to integrate into their daily lives. And we don’t have to reinvent the wheel; there’s a group of organizations set up to do that. We just have to connect the dots; and that’s a key role that a hospital can play.
Is there anything else you’d like to add?
I would just say that the report is really valuable because it pulls together some practices that jumped out as commonalities or lessons learned, so that regardless of who you are or where you’re at, there should be practices that you can implement now. And our best advices is to be proactive and serious about implementing those now, or you’ll be left behind as we move towards more value-based payment models.
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