The need for integrated care is deeply felt in the Brooklyn, New York neighborhood of East New York, which struggles with high rates of poverty, violence, psychiatric hospitalizations, and chronic disease, exacerbated by long standing racial disparities. The COVID-19 pandemic has increased the urgency of integration and pushed this work toward technology-enabled care, including teleconsultation and point-of-care testing. Integration is at the heart of the East New York Health Hub—a marriage of behavioral health and primary care, fostered by a physical and organizational partnership between the Institute for Community Living and Community Healthcare Network, an FQHC. Most clients of the Hub suffer from mental illness, and frequently have experienced trauma that impacts their ability to trust healthcare providers. 

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Through practices like motivational interviewing, harm reduction, and our participant engagement framework COACH, the Camden Coalition’s care planning process has a powerful impact on participant engagement and cross-continuum teaming, and improves patient outcomes. During this webinar, Camden Coalition’s Gladys Antelo, Renee Murray, and Victor Murray discussed traditional and non-traditional care planning, and engagement styles that are essential to providing whole-person care to individuals living with needs beyond healthcare.

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Community health workers (CHWs) play an important role in reaching underserved populations in communities with high levels of complex social and medical needs. At Baylor Scott & White Health System (BSWHS) in Texas, CHWs have been addressing the health and social needs of the community since 2017. In that time, BSWHS has developed a workforce model that not only integrates CHWs into care teams but also hires experienced frontline CHWs as care team supervisors. BSWHS also collaborates with community- and faith-based organizations as well as governmental and local agencies to improve care and empower communities.

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Children with medical complexities require specialized services and care delivery models across the healthcare continuum – from inpatient, outpatient, transitional, respite, home care, and community support services to physicians, nurses, and other providers with the expertise to care for these children. The care system for this population of children is extensive and fragmented, and seldom possesses all aspects of the infrastructure needed to support medically complex children and their families.

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