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Building Community-Based Models of Care

A few months ago, I received a panicked phone call from a neighbor of mine. I hurried over to my neighbor’s house and quickly realized the cause of his alarm: his daughter was passed out in the front room of the upstairs apartment. As my neighbor informed me, his daughter had recently been in jail, and not for the first time. She struggled with substance addiction and dealt with a range of mental and physical health conditions. Though she reached out to several support systems, none could offer the care she required for as long as it was necessary. Consequently, she spent years bouncing between jail, homeless shelters, institutions, and a variety of social service agencies.

My neighbor wished to be of service to his daughter. He is elderly, however, and has little in the way of resources or support to navigate his daughter’s complicated situation. Out of options, his daughter was unable to find a long-term setup that would provide support for her ever-worsening conditions.

This is a stark personal example of how challenging it can be to support individuals and families facing complex care (medical & social) challenges. For so many people, the care they require is much more complex than what our current models are capable of handling. It is because of these limitations in current healthcare services and technology that we must develop new models of care to meet the needs of the most vulnerable individuals in our communities.

Fortunately, there are a number of programs underway trying to tackle the job healthcare and social services organizations are trying to get done together. We’ve been privileged enough over the past 6+ years to work with many of these efforts around the United States. I want to share through a series of posts some of the things we’ve learned about:

  • Critical components of the successful SDOH-focused programs
  • Understanding the key stakeholders that need to be at the table
  • Important lessons about how to think about care model measurement and scale

Critical Components of Community-Based Care Models

As we work with programs around the country, we see four main elements that are essential in establishing new models of care to support the most vulnerable patients. The four key elements are as follows: actionable data, care process configuration, care coordination tools, and analytics.

These elements are central to what we call the CareHub™, a shared space where all of an individual’s healthcare and social service providers can share a care plan, coordinate around tasks and activities, and drive the actions needed to achieve a clear set of patient goals or program objectives. Failure to include these elements in a new care model makes achieving the desired outcomes significantly more challenging, by increasing the cost of care and amplifying the health, social, and operational risks involved.

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Actionable Data

The model starts with what we’ve named actionable data for healthcare and social services, based on model-specific and community-based data sources. I've been a vocal proponent of this perspective for years. In fact, in 2015 I wrote about how to make population health data actionable. While much has changed since then, there is still much work to do.

In healthcare, we talk a lot about big data. It is much more productive to instead focus on data that is relevant to the improvements we hope to achieve, or actionable data. These data sources (payer claims, EHR, HMIS, HIE, etc.) set the context and description of the individuals targeted for a specific care model. Stakeholders building these care models need to be mindful of what data is/is not appropriate for the purpose of both community-based care delivery and community information exchange.

Care Process Configuration

If you study many of the SDOH care coordination programs being deployed around the country, at their core is a specific intervention, or workflow of activities. In the more common care models, these care processes tend to be linear (getting from point A to point B.) They identify a specific condition or social need, as well as the professionals, tools, and technology needed to address the condition or social need.

For the most vulnerable populations (complex health and social needs) the traditional linear models fail because they do not take into account the range of medical and social needs individuals face. For example, giving a patient medication can help manage a chronic condition, but if they walk out of the clinic and are homeless or starving, they simply have more pressing needs that interfere with what's outlined in their medical care plan. Care processes must be configured in ways that take into account cross-community workflows and multidisciplinary plans of care in order to have even a shot of making meaningful progress in achieving the health and wellness goals of people experiencing complex health and social needs.

Care Coordination Tools

We’ve been fortunate to partner with some of the leading SDOH programs across the country. Enabling these programs and care teams to work around a shared, whole person plan of care requires a set of what we refer to as “experiences” necessary to help them do their job. Professor Clay Christensen (also a Co-founder of refers to this as understanding the "job they’re trying to get done", which helps us deliver a tool that helps them do their job better and scale their programs.

It’s critical that communities seeking to implement an integrated health and social care model clearly articulate the job of the care coordinators and service providers such that solutions will be relevant in accomplishing the job. Over the years, we quickly realized that providing a technology solution to help teams working with individuals is helpful, but not sufficient. Without the boots on the ground and other components highlighted in many of these partner programs, these efforts will inevitable struggle.


When we begin discussions with communities embarking on the journey to integrated healthcare and social services, it’s always striking to me just how often these communities fail to identify what they want to measure right from the start. This is the most important step, because from this point the community stakeholders can generate a shared understanding of what data they will need to capture in the course of their work that is needed to validate their results.

Care coordination analytics typically fall into different buckets based on the lifecycle of the care model: process metrics, operational metrics, financial metrics, and patient satisfaction measures. As programs consider the most applicable data, it is essential that program analytics and reporting needs are defined upfront, and also that they can adapt based on the program's evolution and lessons learned.

What's next?

The scale of the costs and the population that require complex care solutions can be overwhelming, and tackling such a monumental issue will require much time and investment. These critical components, however, allow teams to maximize unity and productivity as they identify and work towards meeting the needs of the most complex patients. We invite you to explore some of the complex care programs that supports, and if you are looking to launch or scale your community's program, I invite you to contact us for an expert-led call to learn more.

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