Mapping Community Supports for Patients with Complex Health and Social Needs

Play Strategy
What is a Play? Box

Mapping community resources is a good starting point for developing the system of care needed to interrupt the cycle of hospitalization and emergency department use and create a pathway to health for patients with complex needs. Effective complex care models rest on a foundation of services and supports that go beyond the traditional reach of the health care system. Community asset mapping offers a practical framework for locating and cataloguing a full array of services and for identifying critical care gaps and potential partners.

The goal of this play is to help you get started with asset mapping in your community.


How to run the Play
  1. Identify your target population. Use data from a variety of sources to learn as much as possible about the needs of the population you want to serve.
  2. Create a list of services and supports that your target population will need for stabilization. Services may include, for example, access to behavioral health treatment, stable housing, transportation, addiction services, and pain management. Your list should include formal and informal services and community supports that are currently available, as well as those that need to be created in order to improve health outcomes for community members with complex needs.
  3. Match your list against services and programs currently available in the community. Organizations usually have staff who accept referrals for new clients. These people are good sources of information in terms of assessing service capacity, waiting lists, and eligibility requirements. Verify service availability as well as language and transportation accessibility. Ask whether individuals can get the help they need in a reasonable amount of time at low or no cost. For example, can people without insurance access pain management services without long waits for a scheduled appointment? What kinds of support are available for people who need housing assistance?
  4. Locate formal and informal assets and engage community partners willing to collaborate with you in developing new services and creating an ecosystem of care in your community.
Tips and tricks
  • There are various ways to collect information to complete your asset map. You can do an internet search, interview professional colleagues and patients, and/or do a community survey. Local government websites and 211/311 systems often have current resource directories.
  • Engage experienced case managers from different local or regional health and social services systems to identify the best resources for your specific population.
  • Solicit both the provider and consumer voices in this process. Ask patients directly about what the most important services are to them.
additional resources

This Better Care Play is part of a series developed in partnership with the Camden Coalition of Healthcare Providers to share practical lessons in serving complex populations.