National Center
For Complex Health and Social Needs
- Home
- Research & Resources
- Resources(current)
Resources
-
Caring for children with medical complexity through transformative family partnership
Health equity has taken center stage as our society reckons with the fallout of the COVID-19 pandemic. Vitally important to health equity is authentic partnership with people with lived experience, but that can remain an elusive goal in the context of healthcare transformation. Launched in 2017, the Collaborative Improvement and Innovation Network on Children with […]...Read more
-
Reducing hospital utilization among Native Hawaiians by focusing on social determinants of health
Like many indigenous populations in the US, Native Hawaiians suffer from poor health outcomes as a result of displacement and colonization, which often show up as a high rate of homelessness and fewer opportunities to access education and build wealth. Native Hawaiians are overrepresented as the largest ethnic group experiencing homelessness in Hawaii. As the […]...Read more
-
Best practices and strategies for tele-social care
The COVID-19 pandemic has emphasized and exacerbated the wide inequities in health outcomes and access to quality care that exist for people of color, older adults, people with intellectual and developmental disabilities, and other individuals with complex care needs. Social care — activities to prevent and address health-related social risk factors and social needs — […]...Read more
-
Integrated transitions of care for people experiencing acute mental health crises
In June 2018, Mount Sinai Morningside launched the Mobile Outreach Team (MOT), an innovative program designed to address a substantial gap in acute psychiatric care: warm handoffs with concrete support to assist patients transitioning from an acute hospital-based setting, to ambulatory treatment. Through the use of a person-centered, pragmatic, pro-active engagement approach, future crises are […]...Read more
-
Multi-sectoral alliance resource compendium
This toolkit from the National Alliance to Impact the Social Determinants of Health is intended to support multi-sectoral alliances focused on social determinants of health (SDOH). Included in the toolkit are resources that are useful to stakeholders who are: Interested in addressing SDOH in their community and want to learn more about why multi-sectoral alliances […]...Read more
-
Partnering with communities to improve health outcomes
This e-book resource from The College for Behavioral Health Leadership (CBHL) summarizes what was learned from the CBHL 2020 virtual “Un-Summit,” and provides information on and links to tools used by teams in each of the communities featured; Philadelphia, PA, Austin, TX, and Douglas County, CO. By sharing the case studies and key take-aways from […]...Read more
-
Building effective health system-community partnerships: Lessons from the field
This brief from the Center for Health Care Strategies (CHCS) shares considerations for healthcare organizations and government entities seeking to build effective partnerships with the individuals and communities they serve to better address their health and social needs. It draws from the experiences of two sites that participated in the Community Partnership Pilot, a CHCS […]...Read more
-
Aligning systems with communities to advance equity through shared measurement
In this report, the American Institutes for Research (AIR), with funding from the Robert Wood Johnson Foundation, developed five guiding principles to inform measurement that effectively aligns systems’ actions with the needs and priorities of the communities those systems serve, particularly communities that historically have been harmed the most by inequities. These principles, and accompanying […]...Read more
-
Leveraging value-based payment approaches to promote health equity: Key strategies for healthcare payers
This report from Center for Health Care Strategies (CHCS) and the Institute for Medicaid Innovation (IMI) identifies six connected strategies to guide payers, including Medicaid agencies and managed care organizations, in developing equity-focused value-based payment approaches to mitigate health disparities at the state and local level. These strategies include: Articulating an equity goal Assessing the […]...Read more
-
Complex care at NYC Health+Hospitals: Operational guide to identify, understand, and treat high-need patients
This tool from New York City Health + Hospitals features open-source implementation tools which can be customized and used to support health systems’ efforts to identify, understand, and treat patientswith complex needs. This guide provides step-by-step guidance on: Risk scoring and stratification: using data and analytics to identify patients with complex needs Segmentation: combining analytics […]...Read more
-
“The way home” short-form documentary series
The Way Home is a short-form documentary series from KTF Films and Bread and Butter Films that focuses on the current homelessness epidemic in California — the state with the largest population of homeless people in the USA. The series highlights housing models being piloted in communities throughout California. These films were made possible with […]...Read more
-
Addressing nutrition security amidst the COVID pandemic
This brief from The Root Cause Coalition (TRCC) highlights the stories of five TRCC member organizations and how they have responded to the needs of their communities during the COVID pandemic. The Ceres Community Project, Oregon Food Bank, Share Our Strength, Area Office on Aging of Northwest Ohio and Presbyterian Healthcare Services are the five […]...Read more
-
Tele-social care: Implications & strategies
This guide from the National Center and the Center for Health and Social Care Integration (CHaSCI) at Rush University Medical Center provides on-the-ground lessons, implications, and strategies for tele-social care for frontline staff in both the medical and social sectors. As part of the transition to telehealth prompted by the COVID-19 pandemic, many institutions also […]...Read more
-
Using the complex care core competencies
The complex care core competencies — the knowledge, skills, and attitudes needed by every complex care practitioner — were released by the National Center for Complex Health and Social Needs in October 2020. The competencies are designed to provide a common standard framework for complex care organizations, programs, and teams across the country. In the […]...Read more
-
The state of the field of complex care 2021: A message from the Field Coordinating Committee
The annual message from the Complex Care Field Coordinating Committee this year looks back at 2020 — a year of hardship, sacrifice, and loss, but also resilience, ingenuity, perseverance, and teamwork. Individuals with complex health and social needs were disproportionately affected by the COVID-19 disease as well as by the social and economic impact of […]...Read more
-
Community Ecosystem Learning Collaborative: Office hours
Staff from the National Center for Complex Health and Social Needs presented on the Community Ecosystem Learning Collaborative, a 15-month learning collaborative starting April 2021 that will give teams from across the country the opportunity to develop complex care ecosystems in their communities. During this webinar, staff reviewed the learning collaborative’s goals, the request for […]...Read more
-
National care coordination standards for children and youth with special healthcare needs
This report from the National Academy for State Health Policy and the Lucile Packard Foundation for Children’s Health outlines the core, system-level components of high-quality care coordination for children and youth with complex care needs. The standards are designed to help state officials and other stakeholders develop and strengthen high-quality care coordination for children with the goal […]...Read more
-
Collaboration in communities to address COVID-19
This report from the Robert Wood Johnson Foundation follows nine diverse communities across the US from the start of the COVID-19 pandemic through October 2020. It details how cross-sector collaboration is contributing to ongoing response and recovery efforts. Communities that had cross-sector collaborations in place before the pandemic have been able to rely on strong […]...Read more
-
COVID-19 social health playbook
This playbook from Kaiser Permanente provides guidance on caring for patients with social needs within a COVID-19 context. The playbook includes information on how to assess patients’ social needs, connect them to resources to address those needs, and follow up to ensure needs were met and to coordinate care as appropriate. It is intended for […]...Read more
-
Creating new connections: How philanthropy can support better care of people with complex health and social needs
This report from Grantmakers In Aging and Grantmakers In Health, in association with the Seven Foundations Collaborative, summarizes key issues relevant to understanding complex care and offers resources and case studies for funders interested in entering the field or deepening their existing work. In the hope of engaging more funders and inspiring increased investment in […]...Read more
-
Bringing lawyers onto the health center care team to promote patient & community health
This toolkit from the National Center for Medical Legal Partnership provides the health center community with information and resources to start, strengthen, and sustain a medical-legal partnership (MLP). The toolkit can be used both by health centers new to MLP who want help with the initial planning process and by health centers that are already […]...Read more
-
Building ecosystems for positive change
This report from the Systems Sanctuary provides guide to building and strengthening multi-organizational ecosystems in a community. The report shares common challenges to ecosystem-building, along with insights and frameworks to overcome those challenges. Read the report...Read more
-
Brief: Leveraging the electronic health record (EHR) to link health center patients with MLP services
This brief from the National Center for Medical Legal Partnership describes how the electronic health record (EHR) represents a largely untapped resource to take action on health inequities experienced by patients. The brief focuses on structured data collection and sharing for medical legal partnership programs, but can also be applied to other complex care needs. […]...Read more
-
Community resource referral platforms: Going from 1.0 to 2.0
Community resource referral platforms have been growing in popularity as a way for healthcare and social sector organizations to coordinate services for individuals with complex needs — a demand that has intensified during the COVID-19 pandemic. Promising practices on how to structure and maintain these tools and workflows are emerging, but organizations seeking to implement […]...Read more
-
Increasing inclusion of people with lived experiences
Over the last several months, conversations about diversity and inclusion have become increasingly commonplace. No matter the issue at hand, people with lived experiences understand the challenges and barriers experienced by their communities, and can provide insight into the opportunities to bring about lasting and positive change. While many healthcare and social service professionals support […]...Read more
-
Rush COVID-19 community response playbook: Strengthening our commitment to health equity
This playbook from Rush University Medical Center provides a case study for how health systems can work with residents, community leaders, nonprofit organizations, and other healthcare institutions to be a catalyst for community health and vitality by dismantling barriers to health, and by promoting health equity both within and outside of the institution. It describes […]...Read more
-
5 actions to promote housing access during and beyond the COVID-19 pandemic
This short paper from the American Hospital Association (AHA) describes five actions hospitals and health systems can take to address housing instability and improve health in their communities: Screening patients for social needs and connecting them with community partners Informing patients and employees about available housing resources and protections Providing access to safe, temporary living […]...Read more
-
Data sharing and the law: Overcoming health care sector barriers to sharing data on social determinants
This paper from the Social Interventions Research and Evaluation Network (SIREN) at University of California, San Francisco and Manatt Health addresses legal concerns related to sharing data between healthcare systems, community-based organizations, and others. It sheds light on the circumstances in which healthcare organizations can exchange personal information outside the healthcare sector in compliance with […]...Read more
-
Trauma and equity toolkit
This toolkit from the Center for Community Resilience at George Washington University’s Milken Institute School of Public Health aims to help us collectively see the historical underpinnings of structural racism and the traumas and disparities that result and conduct constructive conversations that lead to policy change. It emphasizes the importance of centering equity at the […]...Read more
-
Direct care work is real work: Elevating the role of the direct care worker
This report from PHI National is part of a series providing a comprehensive, current-day analysis of the direct care workforce and its critical role in the long-term care system in the United States. This report examines the current training landscape for direct care workers. This irregular and under-resourced system fails to prepare workers to succeed […]...Read more
Events & Webinars
Apply to present at Putting Care at the Center 2021
Start date: March 31, 2021
End date: May 17, 2021
Conference | Open call
Improving care transitions for older adults
Date: April 29, 2021
Time: 2-3 pm ET
Webinar
Recent News
-
How can state officials help dismantle structural racism? Lessons from New Jersey
Read the adapted welcome remarks by our CEO Kathleen Noonan for “Dismantling Systemic Racism in Penn...
-
Virtual Student Hotspotting: Using simulation-based education during the COVID pandemic at Samuel Merritt University
By Lillian Khan, BS, 2nd Year Entry Level Master of Science in Nursing (ELMSN) student at Samuel Mer...
-
NJ case study: Using the complex care core competencies to support substance use disorder treatment
By Dayna Fondell, Senior Clinical Manager for Clinical Redesign Initiatives; Shelby Kehoe, Program A...
The National Center for Complex Health and Social Needs is an initiative of the Camden Coalition.