How can we build connections between health care systems, public health, and community partners?
Community and health system partners have common goals of improving the health of people and the communities in which they live.
What drives Clinical-Community Linkages and Coordinated Care?
Clinical-community linkages help to connect health care providers, community organizations, and public health agencies so they can improve patients’ access to preventive and medical care services.1 These approaches can include forming partnerships, coordinating activities to fill gaps in needed services across systems and promoting patient and community involvement.2
Types of clinical-community linkages include coordinating medical care and other community services at a single location and developing ways to connect patients to resources more effectively. Collaborations between clinical, community, and public health organizations offer a win-win scenario for participating organizations, clinical teams, and patients and have been shown to reduce and prevent disease in communities and provide additional support to help patients maintain healthy behaviors.1
- To change the underlying risk factors that lead to chronic diseases and poor health, it is important to reinforce education on healthy behaviors and to support social services needs between clinic visits.2
- Tailoring interventions to community needs and resources is important, as is building a trusting relationship between clinical and community partners and the community members served.3
The Opportunity: How Can Clinical-Community Linkages Be Put Into Action?
Primary care clinicians, public health agencies, and community groups often provide services with little interaction with each other. To build and improve linkages across private and public health organizations within communities, it is important to identify gaps in needed health services and to fill those gaps by using the strengths and abilities of the participating organizations.1
What’s being done?
Here are just a few examples of efforts underway at the state and local level to address this issue:
Whole Person Care Pilots
The California Department of Health Care Services (DHCS), which administers and manages Medi-Cal, California’s Medicaid program, has developed Whole Person Care (WPC) Pilots as part of the federal section 1115 demonstration waiver. The overarching goal of the WPC Pilots is the coordination of health, behavioral health, and social services, as applicable, in a patient-centered manner with the goals of improved patient health and wellbeing through more efficient and effective use of resources. This initiative will provide support to integrate care for a particularly vulnerable group of Medi-Cal beneficiaries who have been identified as high users of multiple systems and continue to have poor health outcomes. Through collaborative leadership and systematic coordination among public and private entities, WPC Pilot entities will identify target populations, share data between systems, coordinate care in real-time, and evaluate individual and population progress – all with the goal of providing comprehensive coordinated care for the patient resulting in better health outcomes.