By: Mavis Asiedu-Frimpong, Director of Communications and Content Development, Camden Coalition of Healthcare Providers
The increased focus of health systems on addressing the social determinants of health is generating exciting opportunities to improve patient care and giving providers a more holistic understanding of patients’ challenges. The new focus on value-based care has prompted health care organizations to think beyond their four walls, creating the impetus and opportunity for new partnerships between health systems and community-based organizations (CBOs) to improve access to resources and supports that respond to social needs.
This emphasis on the relationship between health and social factors highlights important concerns as health systems develop collaborative relationships with CBOs. This interview with Victor Murray, Director of Field Building and Resources for the Camden Coalition of Healthcare Providers, explores the tension between health systems and CBOs and discusses strategies for successfully navigating it.
Q. Now that more health systems are working with CBOs to address their patients’ non-medical needs, what kinds of conflicts arise out of these collaborations?
A: One area of conflict is how health care systems frame the conversation about social factors. I have heard social service workers say that when they listen to hospitals speak about social determinants, it is as if the hospital has made a new discovery, rather than acknowledging that this is something that CBOs have been dealing with for decades with fewer resources and less professional status. This conflict plays out in health system-CBO exchanges, where the hospital may say, “You say you’ve been in this space for years, but why is this patient continuing to cycle through my hospital for non-clinical reasons?” From the CBO side, they’ll respond, “You have the dollars and all the medical information. We don’t have funding for all of the services our clients need.”
CBOs are typically funded by government contracts and foundation grants that do not cover partnership development or the performance and data management systems needed to demonstrate outcomes. Conversely, hospitals in a value-based reimbursement environment are often responding to direction from managed care organizations, where outcomes must be produced in a relatively short time period to claim the highest rates.
Conflicts can also play out around issues of transparency and communication. For hospitals, their resources often only extend to the four walls of their institutions. From the point of view of social service organizations, they often don’t have a window into what’s going on inside the hospital, so they aren’t able to play a bridging role at discharge or intervene before a health crisis occurs.
The biggest takeaway is that collaboration isn’t easy — partnerships are messy. When considering the best way to meet social needs, health systems have the choice to “build, buy, or partner.” Organizations should thoughtfully consider the question: “What would an effective partnership look like?”
Q. How do these conflicts have a trickle-down effect on patient care and delivery?
A: When health system-CBO partnerships aren’t working well, we see competing interests at the patient level. Care is often duplicative when you have primary care providers with their community health workers and health coaches, managed care organizations with their community health workers, and CBOs with their caseworkers or community health workers, all supporting the same patients. This reinforces the fragmentation, lack of coordination and trust, and disconnection that patients experience when engaging with the health system. From a patient perspective, it can be overwhelming and frustrating. It doesn’t improve access or provide the support they need to feel better or prevent frequent trips to the hospital. This problem is due to both duplicative positions (i.e., resource misalignment) and a lack of communication and coordination across systems to manage patient care. Once hired, case workers and community health workers typically work within their own organization, focus on their institutional goals, and rarely coordinate.
Q. How has this tension impacted the growing field of complex care, specifically?
A: In complex care, it’s a given that friction will naturally occur because the field has people from different backgrounds and sectors and with different experiences, all looking at the same problem but from their own lens. But leaders in the field increasingly recognize that these tensions offer opportunities to create a shared mission that will result in better care experiences for patients and practitioners, and a more sensible use of resources for organizations. In fact, the Blueprint for Complex Care — a collaboration between the Camden Coalition, the Institute for Healthcare Improvement, and the Center for Health Care Strategies — promotes a strategy for strengthening a growing community of organizations and leaders committed to this vision of a collaborative, cross-sector, and person-centered delivery model.
Q. What general approaches have been successful in addressing these conflicts and creating mutually beneficial partnerships between health systems and CBOs that are leading to better working relationships and health outcomes?
A: With multiple players with varying interests, it’s important to bring people across sectors, places, and regions together, and solicit as many perspectives as possible. This allows individuals to create a shared vision, develop a complete picture of the problem, and establish a collective path forward. This perspective-taking process mirrors the Camden Coalition’s care planning process, in which nurses, social workers, community health workers, program managers, and lawyers come together to look at a patient through the lens of their respective fields.
Building partnerships looks different in each community due to differences in the available community resources, culture, political landscape, and other factors, so it is important to tailor the approach. In one community, groups may come together over behavioral health access issues, but in another community, the problem might be a lack of providers or a lack of transportation. Because of this, partnership planning often starts with environmental scans and stakeholder mapping.
Q. What strategies have helped the Camden Coalition successfully facilitate collaborations between health systems and CBOs?
A: The Camden Coalition originally formed as part of Cooper Hospital and grew as an organization within the health care space. We’ve evolved into a standalone CBO, so we have the dual perspectives of having worked as part of a health care institution and as a CBO, and can model strategies that foster collaboration:
- We serve as a credible messenger and trusted partner. Our Board of Trustees includes representatives from health care and the social services sectors. The CBO perspective was missing from our Camden Coalition Health Information Exchange (HIE) until we engaged our local health systems and CBOs to understand the types of data they both would find valuable for care management and resource alignment. Because we built relationships across different sectors, our partners trusted us to spearhead this conversation.
- We facilitate collaborative and data-centered care planning. We host monthly care management meetings that bring together providers from across the city to discuss care delivery trends and educate the provider community about programs and services. In facilitating these conversations, we offer a forum for citywide collaboration between health care and other local organizations that serve the same individuals.
- We focus on engagement and build collaborative processes from the start. We work to set a respectful tone in choosing the location for meetings, communicating the agenda, establishing the decision-making structure, and setting goals and priorities.
- We create a safe learning community. We incorporate lessons learned from successes and failures and share them with colleagues to inform future efforts. We also look to other partnership models and are not afraid to adapt and incorporate new learning, especially around measuring progress and success. We’re looking at complex care models delivered through an ACO structure, and models connected to 1115 Medicaid waivers, such as the Whole Person Care Program in California. It’s important that, as a complex care community, we “pop the hood” to find out what’s really happening underneath, so that we can learn from these models and challenge ourselves to do better.
Q. More generally, how can CBOs and health systems set themselves up for success in navigating these conflicts?
A: First, build a space for self- and institutional reflection, and make time for partners to share insights and emerging lessons from working together. Setting milestones, along with measuring outcomes, helps partners track progress. This can mean sharing and using data creatively to understand progress and performance, as well as reporting out to the community and local officials on successes.
We use tools such as community needs assessments, community resource mapping, and stakeholder mapping to develop shared funding strategies for community level interventions, rather than solo institution-based programs. Reporting out on performance is critical, so we identify key community metrics together and commit to achieving them as institutions and collectively — for example, collective efforts can be based on a simple commitment by participating partner organizations to screen patients for social determinants, and share the data for care planning, resource alignment, and reporting.
Second, create an infrastructure to manage the work and the relationships. This means defining roles, deciding who’s accountable for what, and establishing timelines that we stick to. Structure creates the place where trust starts to build. Having a backbone organization — a group or organization that organizes cross-sector partners to transform a fragmented, siloed, or inefficient system with the goal of improving social outcomes — also helps drives progress between milestones.
Third, everyone must have skin in the game. People have to show up, give time, share expertise and their lived experience, contribute financial or other resources within their means, and commit to following up.
Fourth, as an organization, you need to know your limits and be honest about what you can and can’t do. People often leave a meeting with a pile of notes or papers that may not be read again until the next meeting, but establishing rules of engagement, clear assignments, and timelines can really help clear a path to success.
Victor Murray serves as Director of Field Building and Resources for the Camden Coalition of Healthcare Providers, where he designs, iterates, and operationalizes new data-driven interventions that will impact specific segments of the complex needs population.