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Building trust through community health workers in a rural environment
Supporting health-related social needs is increasingly recognized as important in addressing health disparities among vulnerable patients, but a patient’s willingness to engage in social needs screening and support requires trust in their care team. Rural communities’ emphasis on self-reliance and general distrust of institutions are barriers providers often face when seeking to develop trust with […]...Read more
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Collaboratively addressing food insecurity during COVID-19 in urban environments
In the absence of comprehensive economic and antihunger policies, emergency food systems and healthcare organizations have organized to meet increasing demand during the COVID-19 pandemic. In this webinar, we heard from two collaboratives about their strategies to address acute food insecurity in urban environments. We heard how their strategies were tailored to their specific populations […]...Read more
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Information session: National Consumer Scholars 2021-2022 cohort
This virtual informational session was hosted by Evelyne Kane, the National Consumer Scholars Program Manager, as well as Alayna Tillman and Stephanie Burdick, two of our Consumer Scholar alumni. We welcomed people with lived experience who may be interested in applying to be a Consumer Scholar, as well as staff/providers of complex care organizations who […]...Read more
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Building partnerships to care for immigrant communities during COVID-19
COVID-19 has compounded long-standing economic and health disparities, disproportionately affecting Latinos and other people of color. The CARES Act did not confer equal access to stimulus relief or Medicaid to immigrants who are more vulnerable due to roles in essential jobs. To address these structural inequities, organizations like La Clínica del Pueblo in Washington, D.C. […]...Read more
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How health center care teams can address health and housing for patients involved with the justice system
This brief from the National Center for Medical Legal Partnership aims to provide an overview of both the civil and criminal justice systems in the United States, and describes the cyclical relationship between those systems and housing insecurity (including homelessness). The brief outlines potential workflow considerations for health centers working to reduce health disparities for […]...Read more
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Legal and policy approaches towards preventing housing instability
This toolkit from the Network for Public Health Law includes resources that explore state- and local-level legal and policy approaches towards reducing tenant displacement and eviction, and providing supports to prevent housing instability and homelessness. Explore the toolkit...Read more
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Contracting toolkit
This toolkit from the Aging and Disability Business Institute assists in preparing community-based organizations (CBOs) for contracting work by exploring the critical elements of CBO-healthcare contracts. Elements included in the toolkit are: A lexicon of contracting terms Contracting dos and don’ts Guide to insurance in contracting Model contracts for community-based integrated care networks Explore the […]...Read more
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Assessing the impact of complex care models: Opportunities to fill in the gaps
This brief from the Center for Health Care Strategies describes a process used to identify a set of patient- and staff-reported measures for the eight Advancing Integrated Models pilot sites. These measures can supplement traditional utilization, outcomes, and cost measures and support complex care programs interested in expanding their capacity to evaluate care delivery innovations. […]...Read more
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Framework for aligning sectors
This Align for Health interactive framework from the Robert Wood Johnson Foundation offers insights into what elements drive successful efforts to align the healthcare, public health, and social services sectors. These elements help address complex, community-level barriers to good health. Explore the toolkit...Read more
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Managing Medicare beneficiaries with chronic conditions during the COVID-19 pandemic
This brief from the Commonwealth Fund gives recommendation on how to reenvision care delivery models and develop policies and practices that protect Medicare beneficiaries living with chronic conditions after reviewing literature on how COVID-19 impacted these vulnerable populations. The brief: summarizes the ways in which the coronavirus pandemic has affected Medicare beneficiaries living with chronic […]...Read more
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Improving care transitions for older adults
In August 2019, Jewish Association Serving the Aging (JASA), a community-based organization, partnered with Healthfirst, a health insurer, to leverage their strengths and data-sharing capacities to deliver a community-based care transitions intervention supporting older adults with complex health and social needs. The intervention addresses the social determinants of health, prevents avoidable hospital admissions, and enables […]...Read more
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Exploring consumer engagement experiences: A research project co-led by the National Consumer Scholars
Consumer engagement is becoming a popular concept in healthcare, with organizations increasingly understanding the value in working closely with those they serve in order to improve their programs and outcomes. But what are the experiences of the program staff and consumers who take part in consumer engagement activities? A joint project between staff at the […]...Read more
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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“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
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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
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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
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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
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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
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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
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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
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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
Events & Webinars
Shared measurement: Collaborating with communities toward equitable health outcomes
Date: June 17, 2021
Time: 3-4 pm ET
Webinar
Inverting the burden: A health equity strategy for delivering complex care
Date: June 22, 2021
Time: 1-2 pm ET
Webinar
Recent News
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What does the future of nursing look like? According to the National Academy of Medicine, a lot like the complex care field
The National Academy of Medicine recently released “The Future of Nursing 2020-2030: Charting a Path...
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An evaluation of the National Center — and an invitation to help us plan the next phase of our work
By Mark Humowicki, Senior Director of National Initiatives In 2016, with support from the Robert Woo...
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Conducting consumer-led research to explore consumer engagement experiences
By Evelyne Kane, Program Manager for Community Engagement at the Camden Coalition; Danielle Ho...
The National Center for Complex Health and Social Needs is an initiative of the Camden Coalition.