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Collaborative Care Networks
Student / CHOICE Regional Health Network
CHOICE Regional Health Network
Health care capacity is inadequate for vulnerable populations; the number of unemployed continues to grow; hospitals are overcrowded with inappropriate Emergency Department (ED) use; and patient care is severely fragmented. While there are several health-related programs in communities aimed at the disadvantaged, operational and administrative efficiencies are mediocre at best, thereby hindering the patient care coordination essential for reinforcing the health care safety net in volatile economic, political and social environments.
More often than not, a client seeking application assistance for Medicaid is also in need of other social services; perhaps food stamps, housing, transportation, mental health services, and/or employment assistance, to name a few. The current system requires significant effort on the part of the client to obtain these services—effort that this client’s circumstances may prevent him/her from putting forth. Other acute and long-term problems persist: increasing rates of uninsured, unemployed and financially threatened families; the number of Medicaid-accepting medical and dental practices has significantly decreased; Community Health Centers are overcapacity and facing recruitment and retention problems; emergency departments are overcrowded; only about 40% of Medicaid children under the age of six access dental care; and there is an ongoing lack of coordination among primary care, medical specialists, dental care, mental health and non-clinical services.
Vulnerable populations often bring complexity to their care for a variety of medical, behavioral, and socio- economic reasons. The fragmented health care system and fragile health care safety-net create significant challenges for these patients, meaning they are at risk of getting sicker and poorer even though they typically utilize health care services at significantly higher rates. A collaborative and coordinated approach to creating plans of care for these patients will not only strengthen the health care safety net and reduce fragmentation, but it will also provide a higher quality of care for the most vulnerable. Tenets of the Collaborative Care Network include:
• Culturally competent and culture- specific outreach and health care system navigation. This creates access to medical treatment, reduces health disparities in isolated communities, and also increases providers' willingness to accept low-income and/or high risk patients.
• Primary care physician recruitment, including for donated care programs and free clinics. This will increase access to medical treatment and establish medical homes for the uninsured and underinsured.
• Coordination among safety-net programs, including information sharing and common referral protocols. This will eliminate operational and administrative redundancies, creating a more secure and comprehensive plan of care for vulnerable patients.
• Emphasis on case management to mitigate social service needs that keep complex patients from maintaining a medical home or obtaining appropriate medical care.
Collaboration with other organizations and identifying complex, high risk patients could provide the level of coordination needed to actually help these patients and reduce their health care and social service needs. A budding example of this type of collaboration is Sea Mar Community Health Centers' involvement with Community Youth Services (CYS) in Washington State. Every Wednesday, Sea Mar staffs a health clinic at CYS, focusing on wound care, pregnancy, family planning, and other basic acute needs for a growing at-risk youth population. This relationship was formed through CHOICE Regional Health Network, with whom Sea Mar and CYS are both associated.
Engage in community partnerships, contracts, and/or agreements to create a network of health care and social services, aimed at disadvantaged and vulnerable populations. This includes streamlining operative and administrative functions, standardizing referral practices, and creating a shared information hub to best coordinate patient care.
Reference:CHOICE Regional Health Network
Verbiage for pattern card:
Health care capacity is inadequate for vulnerable populations; the number of unemployed continues to grow; hospitals are overcrowded with inappropriate Emergency Department (ED) use; and patient care is severely fragmented. While there are several health-related programs in communities aimed at the disadvantaged, operational and administrative efficiencies are mediocre at best, thereby hindering the patient care coordination essential for reinforcing the health care safety net in volatile economic, political and social environments. Collaborative Care Networks provide the linkages between various community-based health and social service programs and projects, helping to identify and manage the most complex and high-risk patients that typically utilize health care services at disproportionately higher rates.