CCC Archives – PCCI

7 April 2021

“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://pccinnovation.org/connected-communities-of-care/.

###

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.

###

 

23 March 2021

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.

4 November 2020

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:

 

 

Register your team to receive a complimentary set of “Building Connected Communities of Care” and kick off your Executive Book Club with a consultation from one of our experts.

Sign up to receive email updates on PCCI announcements, advancements in the industry, and more!
Loading