Addressing Community SDOH Needs Through Coordinated Care

While the healthcare industry is starting to address social determinants of health, better coordinated care is needed to make a difference for at-risk populations.

By: Greg D'Andrea | May 26, 2022

While the healthcare industry, policymakers, state and local governments, and community organizations are starting to strategically address the Social Determinants of Health, there are still many steps necessary to take in order to achieve the kinds of results that actually make a difference for at-risk individuals. And, just as importantly, set a community up to deliver those results repeatedly time-over-time. 

In many communities around the U.S., organizations are addressing one or two SDOH challenges in a siloed fashion, with no overarching care coordination or strategy for ensuring an at-risk individual has easy-to-navigate access to all the services they need (even though they have the best intentions). While some help is better than none, if we want to make significant, consistent, life-changing and cost-reducing change, we need to be more thoughtful in how we design, build and execute SDOH-centric programs at the community level. 

Outer Cape Community Solutions builds a solid structure for care coordination

Outer Cape Community Solutions (OCCS) is a nonprofit consortium which has a goal of bringing together key healthcare, government and community-based stakeholders to enhance relationships in order to better coordinate care, engage additional resources, and increase overall access to care in the region. The OCCS Network focuses on addressing the unmet SDOH and behavioral health needs within its community. 

The consortium recognized the need to be thoughtful and strategic with early-stage planning, which they saw as critical for long-term, sustainable success. They turned to Activate Care given the team’s extensive experience working with community-based organizations in healthcare to develop strategic plans, bring different groups together to build mutual trust, and ensure everyone not only has a seat at the table, but a voice. 

The outcome of OCCS and Activate Care’s work is a strategic plan and a functioning network that is set up to improve the well-being for residents on the Outer Cape, while measuring, tracking and achieving specific goals. 

This kind of work doesn’t happen overnight. Developing a strategic plan designed to address unmet social needs requires time, patience, collaboration and flexibility. Over the years, the Activate Care and OCCS teams have helped apply and cultivate these attributes and, along the way, identified a few best practices to help community groups organize for improved care coordination. 

Maximize voices for better SDOH and health outcomes

Every organization we have worked with asks us some version of “are you ready to herd cats?” when we get started. They all think they’re unique in the “messiness” of multiple stakeholders, differing opinions and disparate processes. While each organization’s specific challenges are unique to them and their community, the reality is, many are the same regardless of location, size or history. 

Because there are multiple stakeholders coming together – all with the same goal of improving health outcomes for their community – it’s important that every voice is heard. And that goes beyond holding a meeting and expecting input. It means creating multiple avenues and pathways for people to provide their input; for example, leveraging tools that are designed to gather feedback from all kinds of individuals, from introverts to extroverts. 

According to Andy Lowe, Chief Strategy Officer with Outer Cape Health Services, “We are engaging current members more, and getting more active and less passive participation. We’re focused on cross-fertilization of input and ideas, so we can build a more comprehensive, collaborative and inclusive organization. After all, that’s what’s needed to build trust and long-term relationships with – and deliver the right services to – the community we’re all committed to serving.”   

Conduct participatory research to collect SDOH data

Along those same lines, it’s important to quantify (in addition to qualifying) what you are trying to do. With a nod to the old public health days, participatory research can mean the difference between failure and success. For this, the process and execution can make a huge difference; make sure it’s structured and designed to move the organization forward. 

For example, the questions that you ask – and the tools you use to collect the SDOH data – are critical to achieving the kind of consensus that will set the organization up to address key stakeholder and community issues, even if they evolve over time. 

Make health equity your North Star 

No matter the organization or industry, there will always be different dynamics between groups and individuals. That’s why it’s so critical to identify a North Star – health equity – and keep coming back to it. Just creating a network of multiple organizations won’t work; you have to identify the resources each individual and organization brings to the table and the history behind them. Doing so can close the gap between ‘just setting up’ and ‘creating and building for long-term success.’

When individuals bring their own perspective and process, it’s important to understand what’s behind them to understand if they need to become part of the overall organization – its governance, the way it delivers services, or how it identifies at-risk individuals. It goes back to giving everyone a voice; this just takes it one step further: putting that voice through the ‘health equity’ filter to ensure each person carries equal weight, and the ultimate audience – a community’s at-risk population – is treated fairly and equitably.  

Lowe continued: “With the right structure, we’ll be poised for action and implementation, with a roadmap that sets guidelines for the super highway. Those guidelines will help determine the lanes we’ll travel in, and the structure will be much clearer, well laid out and understood by all members, which is critical for us being able to make a real difference in the Outer Cape community.” 

Are you a member of a community or organization that could benefit from improved care coordination across multiple organizations? Learn more about Activate Care’s Path Assist solution.

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