Using Asset Maps to Match Community Supports for Patients with Complex Care Needs: An Interview with the Camden Coalition’s Lauran Hardin


By: Mavis Asiedu-Frimpong, Director of Communications and Content Development, Camden Coalition of Healthcare Providers

Patients with complex care needs often reside in resource-constrained communities where services needed to maintain good health are hard to find and access. One way to overcome the mismatch between needs and available services is to engage in asset mapping — identifying the formal and informal resources in the community that can be harnessed to meet the unique needs of populations with complex health and social needs. 

This Playbook interview with Lauran Hardin, Senior Advisor of Partnerships and Technical Assistance for the Camden Coalition of Healthcare Providers, explores the use of asset mapping to build stronger ecosystems of care, address the root causes of repeated hospital and emergency department utilization, and improve care delivery for individuals with complex health and social needs.

Q. Can you describe the concept of asset mapping for complex populations? What is its potential impact on ecosystem development and care delivery redesign processes in communities?

A: A targeted environmental assessment is necessary to map both the health and social resources that are needed to change the course for individuals with complex health and social needs. This population includes a relatively small, heterogeneous group of people who repeatedly cycle through multiple health care and social service systems, but typically do not derive lasting benefit from those interactions. They often experience a mismatch between their needs and the systems and services that are available to them. The more health care organizations understand these gaps, the more capable they are of building a stronger ecosystem to respond to and ultimately address the root causes of frequent visits to the hospital or emergency department. For example, people without insurance, or even individuals with Medicaid coverage, are often denied access to services or have long wait times to schedule an appointment at a clinic that provides pain management. They then seek treatment for their chronic pain at the emergency department because they’re unable to access the services they need. If health care organizations identify this barrier in the local ecosystem, they can improve access by building out new entryways for expedited care to stabilize patients with complex health and social needs through partnerships with community-based organizations and other stakeholders.

The asset mapping process for complex populations is designed to help identify: (1) the services patients will likely need for stabilization; (2) the existing services available in the community; and (3) the community’s untapped assets that can become a community resource in partnership with the health system. Asset mapping includes activities such as: conducting in-person interviews and site visits with key stakeholders; researching online and doing phone interviews to identify additional resources; and collaborating with key stakeholders to deepen the understanding of community assets. The critical information collected from asset mapping can then be used to co-develop strategies that address the gaps in resources and services for patients with complex needs.

Q. Could you describe how the Camden Coalition’s National Center for Complex Health and Social Needs is working with health systems across the country to adopt asset mapping? What impact has the process had on the specific communities they serve?

A: The Camden Coalition’s National Center has worked with many health system and provider partners across the country to use the asset mapping process to better design their programs and build resources that were missing in their ecosystems. Many of our partners are unfamiliar with the benefits of asset mapping, so we often educate them about those benefits before we start on program design to help accelerate outcomes from the intervention.

For example, we recently worked with Regional One Health, a safety-net hospital in Memphis, Tennessee, to design a care model called ONEHealth to serve the population of uninsured individuals who frequently use the health care system. When Regional One mapped existing resources for their population, they found gaps in access to housing and behavioral health services. To address these barriers, they built a relationship with a behavioral health provider, with whom they now do weekly rounds. Regional One is also considering co-locating staff from the community-based behavioral health provider to work onsite to smooth the transition from hospital to the community. On the housing end, Regional One built an accelerated pathway to housing with housing provider partners from the community. Because asset mapping is a dynamic process, Regional One continues to identify patient needs and build cross-sector partnerships that respond to them. Asset mapping is now a routine part of their care team’s work.

Another example is the Project Restoration model that the Camden Coalition’s National Center developed with the Adventist Health system. Project Restoration is a cross-sector collaborative of health agencies, social services, police and fire departments, emergency medical services, and the education system in Lake County in Northern California. The collaborative engaged in a countywide asset mapping process that examined the core services required for patients with complex health and social needs, such as transportation, housing, behavioral health services, food access, and addiction treatment. The community developed a resource directory from this process, and they are working continuously to strengthen the partnerships and processes that address the identified gaps. For example, they found they had no transitional housing options in their county, so they opened a 10-bed transitional housing facility they call Restoration House. They also hold case conferences with all the agencies serving patients with complex needs to develop shared plans and work on process improvements between agencies. Asset mapping helped them target their intervention, identify new partners, and address service gaps to strengthen their community ecosystem for complex populations.

Q. What are some of the common challenges and pitfalls in the asset mapping process? How have you and the sites you’ve worked with navigated those challenges?

A: Programs that we work with often want to jump right into designing new care models for patients with complex needs because they’re excited about creating something new. But by skipping the step of seeing what is already available for the population, they can end up duplicating services and wasting precious community resources. Also, ignoring existing programs and not integrating work that is already happening in the community can alienate potential service delivery partners.

Another pitfall is viewing asset mapping as a “one and done” experience. Typically, at any given time, there are new services emerging and some services closing in any market. Asset mapping should be viewed as an iterative and dynamic process since there are often new needs and new services emerging in the community. An ongoing process of discovery to find these new partners and resources is essential. It is useful to involve many participants in the process and continue reassessing available resources to ensure that the asset map remains up to date.

The Camden Coalition’s National Center has navigated these challenges by holding annual community-wide events where people can contribute to the shared knowledge of what is available in their communities. We’ve also helped complex care programs build digital platforms for aggregating and accessing community resources using technology solutions like Aunt Bertha or Unite Us so that their lessons are captured in a way that is accessible to many people.

Q. How can entities ensure a successful asset mapping process? What resources and infrastructure need to be in place?

A: A great resource is the Better Care Playbook practical play, “Choose Your Population and Identify Individuals,” which will help in clearly defining the population that will be served. For example, the assets and needs of frail elderly adults living in the community are very different from those of homeless middle-aged adults. Starting with a targeted assessment of the population will save a lot of time.

A: Asset mapping doesn’t have to be a resource-intensive exercise. There are various ways to collect information to complete your asset map — you can do an internet search, or interview professional colleagues, service users, and/or community members. You can talk to experienced case managers from different local or regional systems to identify their best resources for your specific population. It is also important to consider both the provider and consumer voices in this process. Ask patients directly what services are important to them, and from there, do an asset map of the existing resources in their community. This will provide critical information as you develop models and strategies to improve care delivery.

You can also do a more comprehensive version of the asset map by engaging the community in a broader collaborative process. Know your resources and timeline up front, and choose a process you can realistically complete. Remember, asset mapping is iterative, so you can go back and expand on your initial version at a later date.

Lauran Hardin serves as Senior Advisor of Partnerships and Technical Assistance for the Camden Coalition of Healthcare Providers. Through the organization’s National Center for Complex Health and Social Needs, she provides consulting, co-design, and coaching in complex care transformation for health systems and other organizations across the country.