New Trails Navigators and Roots Community Health Center: Putting equity into practice through workforce development

As we wrote in the Blueprint for Complex Care, effective complex care must be equitable. This means addressing the consequences of poverty, racism, and other systemic issues by partnering with individuals with complex needs and their communities — both in identifying barriers and in developing solutions.  Two exciting initiatives, one a brand new startup in...

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Screening for social needs: Guiding care teams to engage patients

This tool from the American Hospital Association is designed to help hospitals and health systems facilitate sensitive conversations with patients about their nonmedical needs that may be a barrier to good health. It includes strategic considerations for implementing a screening program, tips for tailoring screenings to hospitals’ unique communities, case examples and a list of...

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Resource referral guide & template

This guide from Health Leads was developed from a workshop presentation at Putting Care at the Center 2018. The guide was created to help healthcare and community-based organizations create and maintain high-quality resource listings to address clients’ social needs, and includes the steps these organizations can take to better understand and proactively address barriers to...

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Continuum case conferencing for an improved behavioral health system

This brief from Alameda County Care Connect and Bright Research Group details lessons and best practices learned from a pilot complex care intervention for high utilizers of psychiatric emergency services in Alameda County. The pilot convened monthly case conferences with a diverse group of providers from the psychiatric emergency system, County Health Care Service Agency,...

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