Re-imagining Care Coordination for the SDOH Era

Four Requirements of Tech-Enabled Community Health Collaboration

In recent years, Activate Care embarked on a multi-year journey to completely re-imagine care coordination for the SDOH era. Before COVID-19, the company announced its platform technology — Activate CareHub™ — which makes it easy for communities to safely exchange information across sectors. 

Amid the pandemic, Activate Care saw rising social needs and partnered with United Way/2-1-1 organizations and other referral management platforms, helping local community services create opportunities for individuals and families to thrive. 

And in October 2021, Activate Care launched the next generation of sustainable community health interventions with America’s first Community Care Record. Based on feedback and outcomes data from hundreds of client organizations, this solution provides healthcare and social services leaders with a shared space for designing, convening, managing, reimbursing, and continuously improving social interventions at scale.

Four Leadership Factors We Look For

When we engage with different communities and partners around the country, we're often looking for a common set of factors in place that make the work of community coordination possible.

 

Convener

There's a type of convener organization that is usually taking the quarterback role. Managed care organizations might be playing that role, or community services agencies, or local health departments. It depends on the characteristics of each locality. 

There are many models around the country that we support, whether it's whole person care, LTSS, or Medicaid ACOs, or CCOs. Depending on the state where you live, there are specific organizations and entities that are being positioned as the convener, and we're always looking for the organization playing that leadership role. 

 

Network

The second thing we often see is that there's a set or a network of stakeholders that are already engaging each other in the work of coordinating health and social care, often to varying degrees, depending on how far along they are in this journey. But regardless of where they are in this journey, they do struggle, because they don't have the shared space they need to do their work. 

 

Intervention

The third thing we look for is whether there's a specific model of care, theory of change, or set of interventions that are being prioritized. Community leaders know that they can't “boil the ocean” so to speak - so they set out with a focus on a set of priority needs they’d like to address. Then they try to wrap the individuals they serve with a team and a portfolio of resources to address those priority needs. These workflows need to be well understood and well defined in order to scale them via a tech-enabled shared space like the Community Care Record. 

 

Data Sharing

The fourth requirement that these leaders have in common is that they have an appreciation for data sharing, and interoperability across health and social systems. They can also see clearly that they need both the technical capabilities to share data and integrate data, as well as the legal and compliance frameworks for doing so safely. 

 

Four Simple Questions

Are you looking to take your community coordination work to the next level? Ask yourself the following four questions to operationalize your model of care against these four requirements:

  1. How do I build my community network? 
  2. How do I get access to the data elements that are necessary to actually drive action?
  3. How do I share clinical and social information across the network? 
  4. How do I provide the appropriate level of access to stakeholders? 

We designed and built America’s first Community Care Record based on the collective feedback of hundreds of our customers, and our experience supporting the completion of nearly 10,000,000 care activities in our CareHub platform.

The communities we serve have taught us that measurable outcomes require a Community Care Record with the defined tasks, activities, referrals, and team members working within a cross-community workflow. The real work is led by community organizations addressing challenges of housing, food insecurity, and other social needs.