Inside the New England Journal of Medicine Catalyst Article on PCCI’s Successful Management of the Dallas Accountable Health Communities Model

Inside the New England Journal of Medicine Catalyst Article on PCCI’s Successful Management of the Dallas Accountable Health Communities Model

The globally recognized leader in healthcare publishing, the New England Journal of Medicine Catalyst (NEJM Catalyst), has distributed an in-depth article authored by PCCI detailing its successful journey managing the U.S. Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Model in Dallas County1.

To view the NEJM Catalyst article, click here: https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0149

The NEJM Catalyst article offers the results of this five-year initiative, which included partnerships with the region’s top healthcare providers and community-based organizations (CBOs), that demonstrates its positive impact on health care outcomes for some of the most vulnerable Dallas County residents.

The peer reviewed NEJM Catalyst article outlines the purpose of the AHC Model in testing whether systematically identifying and addressing Medicare and Medicaid beneficiaries’ health-related social needs (HRSN), i.e., food, housing, transportation, utilities, and interpersonal safety, through screening, referral, and community navigation services impacts total health care costs and reduces inpatient and outpatient utilization.

The article further describes how bridge organizations (such as PCCI) served as ‘hubs’ in their communities, forming partnerships with their state Medicaid Agencies, local clinical delivery sites, and CBOs. The Dallas AHC (DAHC) included five major healthcare systems (Parkland Health, Baylor Scott & White, Children’s Health, Methodist Health System, and Metrocare Services), Texas Health and Human Services Commission (TX HHSC), and more than 100 CBOs who provided critical social services to meet the needs of residents in Dallas County ZIP codes with high concentrations of unmet HRSN.

Written by PCCI clinical experts and leaders of all aspects of the DAHC, the NEJM Catalyst article offers a comprehensive look at the full five-year initiative in Dallas and its impact on HRSN, utilization, and costs. This analysis includes critical details (and lessons learned) in the DAHC’s planning and implementation as well as methodology, results, and a look forward.

“We are so proud of the opportunity to lead such a meaningful initiative in partnership with CMS, TX HHSC, our participating healthcare systems, and the hundreds of other North Texas organizations who participated. The innovations, learnings, and results are invaluable and can hopefully serve as a blueprint for expanding these efforts regionally and even to other markets in our collective journey to address the social and personal determinants of health of our most vulnerable families,” said Steve Miff, PCCI’s CEO and President. “The significant number of individuals screened and navigated could not have been possible without the amazing support of the hospital systems and many CBOs in Dallas that actually delivered services to the people who came through the DAHC. This article shows the true scope and community-wide effort that makes programs like this successful.”

The NEJM Catalyst article, co-authored by PCCI’s Jacqueline Naeem, MD, Estefania Salazar-Contreras, Venky Sundaram, PhD, Leslie Wainwright, PhD, Keith Kosel, PhD, and Miff, provided strong evidence of the benefit of addressing HRSNs in a comprehensive manner using active navigation within the framework of a connected community of care model that coordinates efforts between clinical and community services.

“The NEJM Catalyst article digs deep into what our challenges were and the steps we took to test how addressing HRSNs improves utilization and health of vulnerable populations,” said Leslie Wainwright, PhD, PCCI’s Chief Funding and Innovation Officer. “Because of the tremendous effort and success we had in identifying, screening, and navigating so many individuals, this article is able to show some clear, thought-provoking results that will give us a logical path forward as we seek ways to address the needs of those most at-risk in our communities.”

The article reports that during the initiative’s five-year course, PCCI and its partners screened 12,548 individuals and identified more than 19,000 distinct needs, with 61% of individuals having two or more concurrent needs. Through the referral process, CBOs provided a multitude of support services, including more than 200,000 pounds of food and $540,000 in utility and rent assistance.

Additionally, the article shows that actively navigated individuals experienced a greater decrease in per-person ED visits.

“This was a tremendous project that garnered some exciting results, which is why the NEJM Catalyst article is so important for sharing how communities can make this work,” said PCCI’s Jacqueline Naeem, MD, Senior Medical Director/Program Director AHC. “But while the article shows important results, this is about more than just data, this is about the people in need who benefited substantially from the screenings, navigations, and participation in the initiative. The stories we heard of the lives we touched during the five-year program is a lasting legacy of the work our entire community put forward.”

In addition to the DAHC work and with the goal to help other municipalities build their own connected communities of care, PCCI also published an in-depth guidebook, “Building Connected Communities of Care.” This is the definitive guide for taking action using social determinants of health, with practical actionable insights from PCCI’s experience building, deploying, and expanding a connected community of care in Dallas. For more information on “Building Connected Communities of Care,” click here: https://pcci1.wpengine.com/playbook/

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[1] This project was supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $4.5M with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.

Achieving Financial Sustainability: A Connected Community of Care’s #1 Goal

By Keith C. Kosel, PhD, MHSA, MBA

Executive Advisor, Parkland Center for Clinical Innovation, and author of  Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations.

 

“Show me the money!” No one old enough to have seen the 1996 movie, Jerry Maguire, will ever forget that memorable phrase. That simple but powerful phrase could apply to every person who punches a clock for a living and just about every business, including community-based organizations (CBOs) and Connected Communities of Care (CCC). For CCCs and other non-profits, a parallel but no less powerful phrase, “No margin, no mission,” also rings true― just ask Sister Irene Kraus of the Daughters of Charity National Health Care System, who is credited with giving health care the phrase. The question is, how do we satisfy these two complementary statements?

When we consider funding for a CCC, we usually speak of seed funding― those dollars provided by a grant or other type of external funding award to establish a new entity or program. Initial planning, design, development, and implementation typically fall under the heading of seed funding. But once the new entity or program is operational and the seed funding is expended, then what? How do we sustain the CCC’s operation? Unfortunately, for most non-profit organizations, that’s when they first seriously ask themselves the question, just before the money runs out and the entity and/or program is placed in immediate peril of failing. This state of hyper-anxiety could have been avoided with some simple sustainability planning initiated very early, during the initial planning phase of the project.

The time to think about how operations will be sustained is not after the entity or program is implemented, but before the first meal is served, the first patient seen, or the first service delivered. For many, especially those new to starting a going concern, this might seem like odd advice and that’s completely understandable. When you are planning, designing, developing, and implementing a new entity or program, you typically have your hands full with a myriad of activities such as hiring team members, decision-making, checking progress, and achieving milestones, revising plans, etc. The last thing you are thinking about is where to get money to keep things going, especially since you have the seed funding check in your pocket, providing a false sense of financial security. But to that initial list of must-dos, you have to include looking beyond the implementation phase to evaluate where the next paycheck will come from and how you will obtain it. To be sure, this is difficult for most organizations to do, but it is essential for the long-term viability of the entity or program like a CCC.

Before we look more closely at the two key elements of financial sustainability – 1) what funders are looking for, and 2) sources of supplemental funding― it is vitally important to state the obvious, which is that sustainability involves far more than just accessing funds. We often talk about operational sustainability, meaning those factors other than money that are essential to keep the organization functioning. Succession planning immediately comes to mind. What happens if the person leading your CCC abruptly leaves or has a major health episode (e.g., heart attack, cancer diagnosis, complications from COVID-19)? We also speak of political sustainability, such as what happens if a new administration takes office and isn’t as favorably disposed to your entity or program as the prior administration? Ever wonder why tech giants and the big Wall Street banks and brokerage firms give money to both parties? That’s political sustainability in action! While all these other types of sustainability are no doubt important, for most non-profit CBOs and CCCs, finding funds to continue operations is, without exception, their greatest concern. Because of that, I will focus my comments on financial sustainability.

Of the two key elements of financial sustainability referenced above, understanding what funders are looking for and ensuring that your new undertaking can deliver “the goods” is paramount to sustaining a CCC. Today more than ever, funders (e.g.,  philanthropic organizations or civic entities, including state and federal grant makers) expect organizations seeking funding for ongoing operations to be able to demonstrate―through valid, demonstrable data― that the programs and services they are delivering are making a difference. No longer are philanthropic organizations willing to simply write a check to non-profit start-ups with the admonishment to “do good with it.” Among other things, given the increasing competition among non-profits for funding assistance, funders are increasingly seeking proof that the new entity, program, or service is making a demonstrable and meaningful difference in the community or among those being served. While this certainly seems like a reasonable expectation, it often catches start-ups by surprise, setting in motion a chaotic chain reaction of panic and grasping at any funding opportunity- even if it’s not related to the core strength of the start-up, that might provide funds, and then more panic when/if that opportunity fails to materialize. To prevent this situation in your CCC, you must BOTH plan for ongoing funding and put your organization in the best possible position to demonstrate that you are making a real difference. So how do you do that? Very simply, you deliver on your promises and generate results that matter.

While that sounds simple enough, it’s what causes most new start-ups, including CCCs, to fail. Having an idea to improve the health and well-being of individuals in the community is simple, but making it happen is much more difficult. Here we are talking about ensuring you can demonstrate to potential funders that you have established realistic stretch goals and supporting objectives for your CCC or one of its programs and that you met those goals and objectives. Have you identified validated measures to track and evaluate performance and do you have a system for helping you collect and analyze the requisite data? Finally, is your program doing what you expected it to do and have you documented every step of the way? These elements are not easy to accomplish. It takes astute planning, a knowledge of the field and immediate market to know what is demanded and valued, and an obsession for tracking all the essential moving pieces. If you can do all of this and your program or service performs as expected, then you will be well on your way to securing the ongoing funding necessary to sustain your operations. As indicated, this is much easier said than done and it is where most new organizations or programs go wrong. Even when your program or service performs to perfection, failing to capture and document that performance (a very common problem among start-ups) can put you squarely behind the eight-ball.

Next, fast forward to results, which have been documented and are turning heads. This means that the funds should just start flowing in, right? Well not exactly. First, you will need to find a funder that believes in you and your data. That’s often not as difficult as it might sound. Start with those you know best― the organizations that provided your seed funding. Assuming the organization that provided your initial funds also funds ongoing projects (some funders do not) and you have solid results, find out if they would be open to continuing to support your work. If they do not, reach out to other funders that know you, assuming your program or service fits within those areas they fund. It is well-known among those in the funding game that funders prefer to fund those they know and those that have consistently delivered the goods. The risk to the funder is considerably less if they know where the money is going, how it will be spent, and if the awardee has a good track record of fiscal responsibility and program results. This is equally true whether you are talking about local philanthropic funders or state and national governmental agencies―building a strong relationship with your funder and delivering result is a proven winning formula.

If the organization that provided your seed funding does not fund ongoing operations, or for any other reason it may be difficult to approach your initial funder or other funders that know you, then you must begin your search for another funding entity. While this process can take some time, especially if you are new to the funding game, it is not that difficult to identify organizations with funding opportunities that may be open to hearing about your results and receiving a proposal. There are numerous information services that identify funding opportunities across the country that can be accessed for free (e.g., www.grants.gov for government opportunities, www.ruralhealthinfo.org for rural opportunities) or for a fee through a subscription arrangement (e.g., www.grantwatch.com and www.grantstation.com), to name just a few. These services cover a wide range of funding opportunities from governmental agencies to local, state, regional, and national philanthropic foundations and can serve as a good way to locate organizations that fund the type of work you do. While there are many professional firms that will do this searching for you for a fee, which is often quite steep, with a little time and perseverance you can do the searches yourself.

At the end of the day, achieving financial sustainability for your new CCC is not that difficult so long as you remember to begin to plan for the need early on during your initial start-up period and, most importantly, you generate solid, demonstrable, in-demand results that funders are eager to pay to support.

About the author

Dr. Keith Kosel, Executive Advisor at Parkland Center for Clinical Innovation (PCCI) and is author of “Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations,” a guide that brings together communities to support our most vulnerable. At PCCI, Keith is leveraging his passion for – and extensive experience in – patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and underserved populations.

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Blog: Is Your Connected Community of Care Making a Difference?

By Keith Kosel, Executive Advisor at Parkland Center for Clinical Innovation

We ask this type of question every day. For example, we may ask― “Is this product that I purchased making a difference?” or “Is this advanced training that I completed making a difference?” Implicit in this common question is the expectation that because we have made an investment in something to achieve a result, the result should be better or more improved than the pre-investment state. So too with a Connected Community of Care (CCC). As I have discussed in previous blogs, establishing a CCC requires a substantial investment in both time and money. Therefore, it is only natural to ask― “Is this CCC making a difference, and how would I know?” Unfortunately, most CCCs are established with very little forethought given to this exact question. While we expect the CCC will help community residents improve their health and well-being, how will we know conclusively that this has happened? How will we demonstrate its impact to a potential partner or― more importantly― a funder? This is where data, measurement, and evaluation come into play. For most people, these three words cause anxiety levels to immediately rise. But this doesn’t need to be the case; a little planning and forethought can go a long way to assuaging one’ anxiety when asked the question, “Is your CCC making a difference?”

Before we think about what data we will need to answer this question or how we will collect it, we first need to establish what we mean by “making a difference”. Understand, there is no one correct answer to this question. What may constitute a positive difference or impact for one organization may be much different for another, even similar organization. Many factors contribute to the final answer and each are usually organization-, ecosystem- and situation-specific.

In practice, there are many ways to define making a difference. First, we can look at quantitative or numeric information to make this determination. Are we providing more nutritious meals to indigent residents? Is the number of inappropriate Emergency Department visits declining or, conversely, is the number of residents having visits with a primary care provider increasing? All of these effects can be counted and judged against some predefined goal (more on this later). Second, we can assess making a difference by asking the people that are being touched by the CCC. Through surveys or brief interviews, community residents can tell you in their own words what impact, if any, the CCC has on their lives. While this qualitative (non-numeric) information can often be more informative than simple quantitative information because it represents the voice of the individual, to answer the question of whether your CCC is making a difference, you will also still likely need to establish numeric goals. A third way to assess whether your CCC is making a difference is indirectly via the financial and non-financial opportunities that arise as a result of having a CCC versus not having one. For example, having a CCC may make it much easier to perform contact tracing among vulnerable populations during a pandemic like COVID-19.

Having a CCC may also enable a healthcare system or a community-based organization (CBO) to apply for a grant that it otherwise might not be competitively positioned to do if it did not have an integrated system of healthcare and social service providers such as a CCC.

Regardless of the approach to define making a difference, the importance of planning for 1) what things will be measured to generate the necessary data, 2) how and when that measurement will take place, and 3) how the resulting data will be analyzed and evaluated, cannot be underestimated.

Similarly, these decisions cannot be put off until a later date as is often seen with start-ups, including CCCs. While it is natural to want to focus on the more immediate needs associated with launching a CCC, deferring the question of how we will know if the entity is making a difference can prove costly, both from an operational and financial perspective. At the Parkland Center for Clinical Innovation (PCCI) we encourage those planning a CCC to devote the necessary time early on to setting performance goals and objectives and determining how and when they will be measured and evaluated. While it is important to explicitly build this step into your CCC planning phase, the scope and scale of the work does not have to be extensive. In fact, at PCCI we strongly encourage CCCs to start small with a limited set of goals, objectives, and requisite measures and then scale up as the CCC grows and matures. This approach has the dual benefit of providing essential core information early on while also not overwhelming the CCC staff with data collection activities that may be a distraction from more pressing, day-to-day activities.

Based on this author’s work with literally hundreds of healthcare and social service provider organizations, experience suggests that most entities (both new and established organizations) do best if they initially establish 1) a limited number of goals― one or two at most, 2) a similar number of objectives to achieve each goal, and 3) no more than three to four performance measures to support each goal. While this may seem like an insufficient number of performance elements in today’s data-obsessed world, remember that you can always add additional goals, objectives, and measures as your expertise and comfort levels allow and as your CCC evolves.

Even more important than the numbers, however, it is essential to get the selection of the goals, objectives, and performance measures correct. Each of these three performance elements plays an essential role in helping you answer the question “Is my CCC making a difference?” Your goals focus on the long-term― what do you ultimately want to happen, while your objectives are the short-term accomplishments that help you achieve your goals. In both cases, you must be sure that what you are expecting is both realistic and appropriate for your CCC’s stage of development. For example, assuming a newly established CCC will reduce ED utilization in its first year or two may not be reasonable and may lead to frustration and disillusionment if the goal is not achieved. If you select a BHAG (Big Harry Audacious Goal), you must allow sufficient time (and then some) for all the necessary pieces to come together. The rule of thumb for large-scale demonstration projects such as launching a CCC is that they 1) take (much) longer than expected, 2) cost more than budgeted, and 3) generally initially deliver less than expected. These facts should not dissuade you from your journey, but rather help you keep things in perspective as the project evolves to one that in the long-term is viewed as valuable in achieving your goals.

If getting the goals and objectives correct is important, then selecting the correct performance measures and designing a feasible measurement plan is paramount. Here again, quality is more important than quantity. A few well-chosen performance measures, implemented correctly, will generate far more in the way of actionable data than a plethora of randomly selected measures. To optimize your ability to assess if your CCC is making a difference, your performance measures should be collected at regular intervals following the launch of the CCC. While many established programs collect, analyze, and evaluate performance data on a quarterly basis, for fledgling CCCs, PCCI recommends this data be collected monthly for at least the first one to two years or until the CCC reaches a stable level of operations. While monthly data collection requires a little more work, the more frequent feedback allows you to make necessary program or operational modifications more quickly and with fewer disruptions than that afforded with quarterly feedback. If measurement and evaluation is an area where you don’t have a lot of experience, reach out to others that do, especially individuals and organizations such as PCCI that have experience assessing performance in large-scale, multi-sector collaborative projects.

While we all hope that the answer to the question “Is my CCC making a difference” is yes, the answer may be no early on in the life of a CCC. As disheartening as this news may be, it’s important to not give up, but to look critically at what is working and what is not and make adjustments where necessary. Usually, this examination does not necessitate a complete “reboot” of the CCC initiative, but rather requires making minor changes accompanied by paying closer attention to the CCC’s operations. Seek feedback from your staff and those you serve and be open to change, where change is warranted. As indicated, these types of projects take a lot longer to reach fruition than most people believe, but with a solid plan, patience, and flexibility, you will be able to answer, “Yes, my CCC is definitively making a difference in the lives of the community residents it serves.”

About the author
Dr. Keith Kosel is an Executive Advisor at Parkland Center for Clinical Innovation (PCCI) and is co-author of “Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations,” a guide that brings together communities to support our most vulnerable. At PCCI, Keith is leveraging his passion for – and extensive experience in – patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and underserved populations.

“BUILDING CONNECTED COMMUNITIES OF CARE” BOOK EXCERPT Case Study – Engaging Patients—Location and Relationships Matter

Following is an excerpt from PCCI’s book, “Building Connected Communities of Care: The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations.” This is a practical how-to guide for clinical, community, and government, population health leaders interested in building connected clinical-community (CCC) services.

This section is from Chapter 6, “Clinical Providers Track.” The purpose of the Clinical Providers Track is to set out the stakeholders and processes required to integrate clinical entities, insights, programs, interventions, strategies, and measurement for the CCC.

PCCI and its partner Healthbox, offers readiness assessments as a service. If you and your organization are interested, go here for more information: https://pcci1.wpengine.com/connected-communities-of-care/.

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Case Study: Engaging Patients—Location and Relationships Matter

As part of our CCC history, PCCI has developed and tested a number of approaches to identifying individuals within the population of vulnerable and under-served Parkland patients who could benefit from screening for health related social determinants, engaging them in the completion of a brief risk assessment and subsequent linkage to available community resources. As with many of the elements of the CCC, this proved to be a learning experience in which initial, more conventional approaches gave way to new and more innovative approaches of engaging this population to optimize goal
attainment.

RECRUITMENT
Much of the initial work began with screening in the outpatient setting. Parkland has 12 Community-Oriented Primary Care (COPC) clinics located throughout Dallas County to serve local residents. Because the COPCs see a large number of patients on a daily basis, many of whom are considered vulnerable and underserved, these COPCs were determined to be a great
location to conduct the social determinant risk assessments. When a patient checked in for a visit, the office staff would provide the patient with a paper-based screening tool to self-administer. Trained community health workers were available in the waiting area to help, if required. Initially we felt like this approach made sense since the large number of COPC patients translated into large numbers of completed screening surveys. However, while there were a large number of initial screenings, the number was very low of patients that agreed to engage with a PCCI community health worker to connect with local community services. Many stated they were not interested or needed to leave the facility for another commitment. Other patients completed the needs assessment but left the COPC before staff members were able to connect with them. Of these, very few responded to follow-up phone outreach and the ones that did were hesitant about referral to community-based services. The team attributed this gap to the lack of personal engagement at the point of initial screening.

As a result of this initial experience, the team made some changes to the screening protocols. Three concurrent workflows focusing on different points of patient encounters were designed and tested. The three new points included: (1) engagement while the individual was in the ED, (2) engagement of individuals that had already left the ED, and (3) engagement of hospitalized patients on the medical/surgical floors of the hospital.

For the direct engagement while the individual was in the ED, licensed social workers conducted initial face-to-face screenings with patients awaiting care. The social workers were provided a list of eligible patients (those with multiple ED visits in the past year) and went room to room to conduct the screenings and determine if the patients were interested in connecting with community resources. Because many of these patient interactions took place while the individual was in the middle of an ED care visit, the PCCI team member was mindful of this and stepped aside, as needed, to ensure they didn’t interrupt the patient’s care. For those individuals that left the ED before screening, the PCCI team placed these individuals’ names and contact numbers on a sheet and later reached out to them by phone to explain the program and ask if they were interested in receiving information on community resources.

Finally, for those individuals undergoing an inpatient stay in the hospital, PCCI personnel obtained census data reports with information about eligible patients and then staff visited these patients in their rooms to conduct one-on-one conversations to implement the screening tool and to determine if the patients were interested in receiving more information about navigation services to community resources.


As shown in Table 6.1, a key learning from this undertaking was that the site matters in conducting the screenings and successfully connecting people to local programs for support. We learned that engaging patients during their inpatient stay was the optimal care setting in which to conduct screenings and then connect those patients to the appropriate community resources.

Establishing trust with patients early in the process was essential, both for completing the initial screening tool and for facilitating connection to community services. During our initial approach, we relied on self-administered screenings that provided little in the way of opportunity to establish a relationship with patients. Our modified workflow allowed our social workers and community health workers to verbally administer the screening tool and provide additional explanations as part of that exchange. This process also made the transition to navigation services virtually seamless and much more
effective. Feedback from patients has also been positive; most indicated that the information received was useful and many said they would share this information with other family members and close friends.

THE SCREENING PROCESS
The PCCI community engagement team consisted of six community health workers and two master’s-level, licensed social workers. Initially, the team consisted entirely of social workers, but our experience taught us that a blended staff model was more cost-effective. PCCI physician leaders coached all team members on how to be flexible and professional when working in the ED, where care moves at a rapid pace. The team needed to take cues from medical staff on where and when to step in to conduct the screenings. Similar trainings were delivered to those staff visiting patients in the hospital.

Over the course of the 6-month pilot, we were also able to identify a number of key elements that increased both the effectiveness and efficiency of the screening process. For example, we learned that it took on average 15 minutes to complete the assessment tool when it was facilitated by a team member but only 10 minutes when self-administered. While the self-administered survey took less time to complete, we found a much higher percentage of incomplete and inaccurate responses, making many of the screens useless. As would be expected, we also found that older patients—those 65 or older—took on average 20 minutes to complete the facilitated screening survey while younger individuals completed it in half the time. The difference was attributable to the amount of questions asked and attendant conversations, which were much more prevalent with older patients. Finally, once we began to work more closely with the patients and they developed a better sense of the purpose of the work, we encountered very few issues with obtaining consent from the patients to share their information with others.

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Governance: The Glue That Holds Connected Communities of Care Together

By Keith C. Kosel, PhD, MHSA, MBA

Aligning groups that have very different backgrounds and agendas, for the good of the community, is no easy matter. Whether at the city, state, or federal level, governmental or civic entities are tasked with trying to build consensus among various stakeholder groups to affect an outcome that works for the constituents they represent. It is no different for those tasked with leading a Connected Community of Care (CCC).

The Role of Governance
The premise behind the CCC is that by bringing together healthcare providers, community-based social service organizations (CBOs), faith-based organizations, and various civic entities, a community can establish a network of care providers focused on addressing residents’ social and/or clinical needs. While the premise is straightforward, establishing the governance group and governance structure to set up and manage a CCC is anything but straightforward. Before we look at how we might bring entities with different missions and agendas to the table, let’s understand what we mean by a governance group and a governance structure, and why these are essential to form a successful CCC.

The nucleus of a CCC is its governance group― those organizations that have come together to establish the CCC and to form the rules by which it will operate (the governance structure). As most CCCs form from scratch, the governance group is typically made up of one or two organizations we refer to as Anchor Organizations. These are typically large, well-established, and highly respected organizations within the community. They could include national social service organizations such as the United Way or Salvation Army, or they could be philanthropic funders, faith-based organizations or healthcare systems. What all these organizations have in common is a mission to improve the health and well-being of their community’s residents. As such they lie at the heart of the governance group (Figure 1).

Figure 1. Connected Communities of Care Including Governance Structure

In addition to the Anchor Organizations, the governance group typically consists of four to six additional Partner Organizations. These may be somewhat smaller CBOs (in scale and scope), but they all play a foundational community role in addressing resident’s social and/or clinical needs. Partner Organizations are well-known within the community and historically work closely with the Anchor Organizations. Partners could be regional food banks, housing assistance providers, crisis centers, mental health providers, local school districts, etc.― all defined by the fact they deliver essential social or clinical services within the community.

The role of the governance group is to provide structure and guidance for the CCC. By structure we mean things like: (1) how network participants will be identified and approved, and what will be expected of each; (2) what the CCC’s mission and charter will include; (3) how the CCC will be funded; and what type of data must be collected and shared, consistent with HIPAA regulations. While the governance structure deals with establishing the rules and policies that guide the day-to-day workings of the CCC, the governance guidance function focuses on issues like: (1) support for a Readiness Assessment (See previous blog) to determine if the community needs― and is even ready for ―a CCC; (2) how and at what rate the CCC should grow; (3) strategic partnerships; and (4) CCC sustainability. A governance group is essential to establishing and growing the CCC. Moreover, without a strong, representative and resilient governance group, most CCCs will eventually fail.

Act 1 -Forming the Governance Group

While we might think that forming the Governance Group would be a fairly easy task, given that many Anchors and Partners already know one other, in reality the process is far more complicated. While many of the Anchor and Partner Organizations work in parallel, they often have a narrow topical focus, such as providing food, housing, healthcare or after-school programs. These topical focus areas may conflict either with regard to the purpose of the work or the process by which the work takes place. As an outsider looking in, we might think these are minor, easily solved issues when in fact they are anything but. Layer on top of this funding mechanisms that often are not uniform or are based on an organization’s own performance to support its mission within the broader CCC, and simple differences compound quickly. As the number of Anchor and Partner Organizations increases, the complexity of achieving alignment among these entities also increases dramatically. This is the point where the presence of a powerful and commanding Anchor Organization(s) become critical in driving alignment.

Because there are usually only one or two Anchor Organizations, the likelihood of disagreement is minimized, compared to the next governance level down (i.e., Partners). Typically, the Anchor Organizations individually have been contemplating a Connected Community of Care for some time and all it takes is the right “spark” at the right moment to bring them together. Further, Anchor Organizations by their nature are well versed in coalition building and working across multiple sectors, which is a skill set that may be less well-developed in the Partners, especially in smaller or rural communities.

A key function of an Anchor Organization is to bring a handful of Partner Organizations into the governance group. Here the Anchor’s skill in selecting collegial partners or ones that can easily be won over to align with the CCC’s mission and goals is extremely important. Including a Partner that will be disruptive or non-cooperative is a fatal error, regardless of what resources that Partner might control. Even if it means working harder to secure the necessary resources, it is better to include only cooperative and committed partners than to access resources at the cost of major disruption.

Act 2 – Moving the Governance Group Forward
Establishing a highly cohesive and well-functioning governance group is only the first step in an ongoing process to grow a successful CCC. The governance group must continue to evolve along with the CCC network. As the network expands, there may be a need to increase representation within the governance group. While warranted, this process must be handled carefully to avoid the disruption just mentioned. At the same time, the governance group may need to remove some participants from the network for failing to follow the CCC’s charter or for sub-standard performance. Although these are difficult decisions, neglecting to make them can irreparably damage the entire CCC over time.

In wrestling with these decisions, the governance group must always be focused on sustainability – sustainability of the CCC and of the governance group itself. Sustainability of the CCC takes different forms from operational sustainability to financial sustainability, each of which are indispensable to a CCC’s long-term growth and viability. Operational sustainability focuses on the challenges of keeping the CCC network up-to-date with regard to technology, strategic partnerships, growth through additional participants, and ongoing social and health needs assessments (i.e., is the prevalence of obesity increasing silently in the community? Are more people accessing utility assistance in the face of declining employment as businesses relocate to more favorable locations?). It also includes provisions for turnover at both the CCC administrative level and at the level of the CBOs, which historically have high turnover levels due to numbers of volunteer staff, etc.

Achieving financial sustainability is the ultimate challenge facing CCC governance groups. Without sustained funding, whether through internal or external means, a CCC cannot survive long term as an effective functioning network. The real challenge is not only securing funding but doing so in a way that benefits all network participants in some fashion based on need and contribution. When network participants must seek funding on their own, inequities are prone to develop, as participants begin to follow their own interests rather than the collective interest of the CCC. Though a difficult challenge, especially in today’s pandemic environment of scarce funding, CCC governance groups must confront it head-on.

CCC governance is not an easy or straight road. Rather it is strewn with potholes, stop signs and detours- but one that must be followed none the less if a CCC is to achieve its goal of improving the health and well-being of the community and its residents. The time and thought that goes into establishing a cohesive and highly effective governance group and structure will pay dividends to the CCC and those it serves many times over as the CCC grows and matures to become a key fixture within the community.

About the author
Dr. Keith Kosel is a Vice President at Parkland Center for Clinical Innovation (PCCI) and is author of “Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations,” a guide that brings together communities to support our most vulnerable. At PCCI, Keith is leveraging his passion for – and extensive experience in – patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and under-served populations.

HIMSS Webcast II: Connected Communities of Care and the Community Health Needs Assessment (CHNA)

https://www.himsslearn.org/connected-communities-care-and-community-health-needs-assessment-chna

Understanding community need has been a core aspect of hospital operations, especially for organizations with a non-profit status.  As we gain greater insights into the impact of non-medical determinants and their impact on positive health outcomes, there is a heightened imperative to revamp how CHNA activities are undertaken and the type of data that are collected.  This session will speak to how organizations who have been on the front lines of SDOH work have altered their approach to their CHNA to gain deeper insights to better contextualize the true needs of their communities. This webcast features PCCI and Healthbox leaders:

Please have a look at the full set of HIMSS Webcasts featuring PCCI and Healthbox discussing how to implement SDOH principles via connected communities of care: