Evolving healthcare delivery models emphasize community care coordination to improve patient outcomes and reduce costs in the US health system. Community care coordinators facilitate collaboration among various providers to address comprehensive patient needs through innovative models like accountable care organizations and patient-centered medical homes. Effective data sharing and interoperability are essential in these networks to support the treatment of individuals with complex health and social issues.

1. Evolving
Healthcare
Delivery Models
Demand
Community
CareCoordination

2. US Health and Human Services
is in Transition
The cost of healthcare continues to rise without a
corresponding increase in patient outcomes
INCREASED
PROVIDER COSTS
POOR HEALTH
OUTCOMES

3. US Health and Human Services
is in Transition
Provider payments have shifted from
FEE-FOR-SERVICE OUTCOMES-BASED
TO

4. US Health and Human Services
is in Transition
TO
Communities are shifting from
TREATING HEALTH
PROBLEMS
TRYING TO
PREVENT THEM

5. Preventative Care
Some of the key areas of preventative care include:
Addressing all aspects of a
person’s health, including
primary care, behavioral health,
and social supports
Reforming the healthcare
delivery system
Holding providers
accountable for
sustainable outcomes

6. IMPROVED CARE
IMPROVED OUTCOMES
REDUCED COSTS
With funding for
innovation, there are
many innovative care
models:
• Patient-Centered Medical
Home
• Medicaid ACO Learning
Collaborative
• Accountable Health
Communities
• Certified Community
Behavioral Health Clinics
Demand for Innovation

7. Introducing Community
Care Coordination

8. What is community care coordination?
An array of providers in
the community treats the
full scope of patient
needs jointly
Providers share data
across multiple agencies
for a whole-person view
of patients
URGENT CARE HOSPITAL
HOME HEALTH PRIMARY CARE OFFICE
Value-based
Payment Models

9. Goals of Community Care Coordination
Support enhanced
access to
high-quality care
Improve patient
outcomes
Deliver
evidence-based care
and improved
community
population health
Ensure effective
communication,
coordination, and
integration with other
providers

10. New Care Models Require
a New Care Role

11. Introducing the Community Care Coordinator
The terms case manager, care manager, and care
coordinator are often used interchangeably, but
there are distinct differences
CASE
MANAGER
CARE
MANAGER
COMMUNITY CARE
COORDINATOR

12. Case Manager
Usually works on behalf of
human service programs such as:
• Housing
• Workforce services
• Food assistance
• Youth and family services

13. Care Manager
• Usually works in clinical settings
to address medical needs
• May refer patients to multiple
providers within a facility or
health system

14. Community
Care Coordinator
Works closely with a variety of providers in a
community health neighborhood to address all
aspects of a patient’s health
CASE
MANAGER
CARE
MANAGER

15. What is a Community
Health Neighborhood?

16. Community Health Neighborhood is a network
of community caregivers and recipients of care
in a specific geographic area
Coordination across
multiple service
organizations from
multiple disciplines
Data sharing
and real-time
communication
A focus on improving
the overall well-being
of the community

17. A Connected Network of Services
Outpatient Substance
Use Treatment
Patient Centered
Medical Home
Primary Care Office
Home Health
Youth and
Family Services
Comprehensive
Care Clinic
Patient
Accountable Care
Organization
Workforce
Services
Hospital
Urgent Care

18. Benefits for Providers Participating
in a Community Health Neighborhood
Coordinated screenings Enhanced coordination
of patient care
Single point of entry
assessment and referral
for service
Increased treatment
adherence
Decreased duplication
of services
Increased understanding
by providers

19. Community Health Neighborhoods
Take Various Forms
Accountable Care
Organizations
Regional Health
Improvement
Collaboratives
County Medicaid
Whole Person
Care Programs
Coalitions of
community
providers
1 2 3 4

20. DATA
DATA INTEROPERABILITY:
The Community Postman
Data Interoperability is the
postman in the community
health neighborhood
Data is readily available to all
partners in the health
neighborhood

21. Importance of
Data Sharing
You can’t treat the whole person
with only part of the data
Data enables providers to collectively
address social determinants of health,
behavioral health, and primary care needs

22. HEALTH NEIGHBORHOOD IN ACTION:
Case Study
LA County Whole
Person Care
Medicaid care
coordination pilot
program targeted at
the county’s most
vulnerable residents
Homeless
Population
Residents involved
with the criminal
justice system
High-risk mental
health patients
High-risk medical
patients
Residents with
substance use
disorder

23. “These are not the average clients that
have a handful of issues that can be
addressed predominantly in one or two
settings. These are individuals that
often have multiple case managers
working across multiple settings.”
DR. CLEMENS HONG
Director of L.A. Whole Person Care

24. HEALTH NEIGHBORHOOD IN ACTION:
Case Study
LA County care
coordination
system
Medicaid care
coordination pilot
program targeted at
the county’s most
vulnerable residents
Simplifies data
collection
Streamlines data
presentation
Provides evidence-
based knowledge
Stores and transmits
thousands of records
Gives providers a
longitudinal patient
care plan

25. Conclusion
A successful community care coordination
model includes:
• The capture and management of health and
social determinant data
• Interoperability to support the sharing of that
data among health and community providers

26. Conclusion
Click to Download the White Paper