La Plata County Community Care Hub (laplatacares.org)

Multiple community health needs assessments conducted locally have identified issues with healthcare accessibility, affordability, and availability in La Plata County. Local healthcare providers, public health departments and community-based organizations (CBOs) are working together, as well as independent of one another, to address these needs.  Among the identified areas of need/demand are:

• Behavioral health including substance use and related disorders
• Access to and availability of care (primary & specialty)
• Social determinants of health (SDOH) – stable and safe housing, food security, transportation, employment, finances
• Healthcare & social care resources navigation
• Senior services

Community Care Hub Concept

Communities across the country are dealing with similar issues and there is a growing movement where healthcare organizations, public health systems and CBOs are partnering to create community care coordination systems. Referred to as Community Care Hubs (CCH) or Care Coordination Hubs, the CCH is managed by a neutral entity that gathers existing local CBOs and care coordination providers and entities together into an organized, collaborative network.  The CCH relies on these local care coordinators (i.e. community health workers, patient navigators, health advocates) working within existing local healthcare and social service entities to:

1. Engage community members in need of assistance
2. Enroll them in the CCH via an online platform
3. Assess their health and social service needs
4. Refer them to and/or assist them with accessing the appropriate care or social services
5. Follow up to monitor/track compliance, and document their progress on a regular basis

Ideally, participants meet face-to-face or virtually with the referred care coordinator to receive support with:

• Non-medical, health-related “social care”
• Chronic disease prevention & management
• Health promotion/preventive medicine
• Health literacy and advocacy

Among the services the typical CCH provides are:

• training and support of local care coordinators, to assist with identifying those in the community at greatest risk or in need of assistance with care coordination
• implementation, management and support of a system-wide IT closed-loop referral platform connecting participating organizations
• tracking and reporting usage and patient/client outcomes
• community education and promotion of the services of the hub’s CBOs and healthcare providers

In addition, the CCH may also:

• facilitate collaboration between local entities that have requirements to conduct periodic community health needs assessments
• participate in developing community health intervention strategies
• develop and manage a web-based, community healthcare data dashboard (addresses local provider availability, claims data, population health metrics, etc.)

Specific examples of the high-risk populations the CCH addresses include:

• Individuals at risk of long-term nursing home placement
• Individuals making frequent use of emergency departments and urgent care
• Individuals at risk for hospitalizations and/or hospital readmission
• Individuals with a specific chronic illness or multiple chronic conditions
• Individuals who are dually eligible for Medicare and Medicaid
• Individuals living with dementia and their caregivers

Examples of lower-risk populations include individuals in need of assistance with:

• accessing and navigating the local healthcare system
• accessing and navigating local social service agencies (housing, food, employment, transportation, child care, pet care, etc.)
• insurance enrollment
• medical billing issues

Referral Sources to the CCH

• Healthcare providers                 • Faith-based organizations
• Public Health Department         • Community-based organizations
• Emergency responders             • Schools and colleges
• Health fairs, screenings, etc.     • Employers
• Self-referral
• criminal justice system (mentioned below) , family members, long term care/rehab facilities, fitness facilities, wellness programs, coaches, etc.

Potential Funding Sources (excerpt from National Library of Medicine article)

The financial sustainability of ACHs (accountable communities of health – a type of community care hub) is an ongoing topic of concern. ACHs are often initiated with philanthropic or publicly funded startup grants, but additional resources are required to sustain both the programmatic and core infrastructure functions of these organizations in the long term. Identifying and obtaining financial support for core infrastructure functions is of particular concern because, although experts have identified multiple credible funding options for ACH infrastructure activities, “there is no dedicated or explicit source of funding for these critical functions” (Hughes and Mann, 2020). Some ACHs have developed services they can charge for, and others have developed relationships with insurance providers such as Medicaid or private insurers that participate in Medicaid contracts. In Washington State, several ACHs used resources from the Medicaid Transformation Project (MTP) to fund Community Resiliency Funds, which many used to fund improvements in the social determinants of health in their communities. The California Accountable Communities for Health Initiative (CACHI) projects were encouraged to establish Wellness Funds, which could be funded with dollars from a variety of sources, such as managed care organizations participating in the state Medicaid program. The ACHs with these special funds found them to be extremely helpful in meeting the needs of populations at high risk during the height of the pandemic. Nevertheless, developing the business case for ACHs remains a challenge.

Patient Stories (videos) from CONNECT Santa Fe Community Care Hub

• Debora
• Tony
• Sayra

Patient Scenarios from Colorado Social Health Information Exchange (SHIE)

• Adrian & Lucia (pdf)
• Vanessa & Caroline (pdf)

Essential Elements of Accountable Communities of Health

References

Community Care Hub Models/Examples

• Overview of Community Care Hubs
• Evolution of the Community Care Hub Model to Align Social Care with Healthcare
• Common Spirit Community Health Initiatives
• Pathways Community Hub Institute Model
• Pathways Interventions & Desired Outcomes
• Accountable Communities for Health (ACHs) (excellent overview of various models of community care hubs)
• BUILD Health Challenge
• Breaking Down the Basics of Patient Navigation, Care Coordination

Proposals and Planning Documents

• Colorado Department of Health Care Policy & Financing (HCPF) – Accountable Care Collaborative Phase III Concept Paper
• Connect2 Community Network Plan (King County, WA)
• Laying the foundation for a community information exchange in Utah
• Social Determinants of Health Information Exchange Toolkit (see page 71 for CommonSpirit info)
• Community Information Exchange Toolkit (San Diego)
• Functions of a Mature Community Care Hub
• CONNECT (Santa Fe) – Outcome Evaluation Methodology
• Pathways Community Hub Manual

Case Studies/Research 

• Community Health Workers: Evidence of Their Effectiveness
• Common Spirit Connected Community Network Case Study
• Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives
• Improving Health And Well-Being Through Community Care Hubs

Referral Platforms

• Community Resource Referral Platforms: A Guide for Health Care Organizations
• Unite Us
• Social Solutions
• 2-1-1 Colorado
• CIE San Diego
• CIE (Community Information Exchange) Toolkit

 

Local Healthcare & Social Service Organizations

Providers & Agencies

• Mercy Hospital
• Axis Health System and La Plata Integrated Healthcare (Care Coordination)
• Animas Surgical Hospital
• San Juan Basin and La Plata County Public Health Departments
• Pediatric Partners of the Southwest
• Other independent providers (Durango Network?)
• Rocky Mountain Health Plans (Medicaid Regional Accountable Entity)
• Southern Ute Tribe
• 4 Corners Children’s Clinic
• McCrea Family Practice, direct primary care

Social Services (also see Children’s and Senior Services below)

• United Way (FamilyWize Rx savings and Team-Up)
• Companeros
• Southern Colorado Community Action Agency
• Community Connections
• La Plata County Human Services Department
• Emergency Responders (police, fire, paramedics, etc.)
• Volunteers of America
• Southwest Center for Independence
• Women’s Resource Center
• N.I.N.A.

Senior Services

• San Juan Basin Area Agency on Aging (AAA)
• Durango Dementia Coalition
• La Plata County Senior Center
• Pine River Senior Center

Children’s Services

• Durango School District
• Bayfield School District
• Ignacio School District
• Early Childhood Council of La Plata County
• Tri County Head Start
• La Plata Family Centers Coalition (Family Advocate & Resource Coordinators)
  San Juan BOCES
• La Plata Youth Services Collaborative Management Program

Veterans’ Services

• VA Clinic
• Veterans Outreach Center of La Plata County
• Veterans Services Office

Affordable and Safe Housing

• Housing Solutions for the Southwest
• Regional Housing Alliance of La Plata County
• HomesFund
• Southwest Center for Independence
• Volunteers of America
• Alternative Horizons
• Habitat for Humanity

Food Security

• EAT FAIR Coalition
• Manna
• Good Food Collective / Food Equity Coalition
• Old Fort
• Durango Food Bank
• Bayfield Food Bank
• Pine River Shares
• Colorado Peak (SNAP)

Transportation

• Durango Transit
• Road Runner Transit
• Southwest Rides
• DuranGO Microtransit

Behavioral Health/SUDs

• SJBPH
• Axis Health System
• SWORD

Misc.

• Southwestern Colorado AHEC