At the upcoming Community Information Exchange Summit in San Diego in March, one presentation will describe the Collaborative to Advance Social Health Integration. Launched in May 2018, CASHI brought together 21 primary care teams and community partners from across the country to find ways to improve and grow social needs pilot programs across their organizations and work toward financial sustainability.
Supported by Health Leads and The Commonwealth Fund, CASHI was created as an 18-month collaborative to develop implementation guidance in areas where social health integration know-how was limited but critical for effective delivery of whole-person care. A recent report on lessons learned described CASHI’s four key focus areas:
• Accelerate practice on key drivers of health equity including patient/community engagement, community health worker integration and support, and cross-sector collaboration.
• Test patient-reported outcome measures (PROMs), which are required to measure social health impact, but difficult to collect and report.
• Plan for financial sustainability by creating an enduring and practical process for business case development.
• Move beyond pilots to spread essential resource navigation as an integrated part of care across many sites.
Among the participants were Dayton Children’s Hospital, Northwell Health, Virginia Commonwealth, Reading Hospital in Pennsylvania, Kentucky One, UH Cleveland, Rush University, OHSU Health and Rogue Community Health in Oregon, Mercy One in Iowa, Truman Medical Centers in Missouri, and Children’s Minnesota.
Informed by their communities, faculty guidance and their peers, the CASHI report said, teams made important changes to many aspects of their work including screening and assessment tools and approaches, support structures for patients and staff, and strategic partnerships with community-based organizations. Fifteen teams spread their social health approach to over 70 new clinics in just 18 months, and 70 percent of teams worked with patients, through patient advisory councils or focus groups, to co-develop or improve their social health approach for maximum impact.
The CASHI teams sought to build trust and share resources, data and decision-making with community partners. Some are strengthening partners’ capacity or adding community partners to their care coordination networks. For instance, Rogue Community Health in Oregon has a “no-wrong-door” community hub in which they are a member alongside community-based organizations.
Rogue engages in community building and shared visioning with each of the partners in the hub, with routine meetings among partners at all levels. They used a shared technology platform for direct referrals between partners, reducing intake burden for members and entering goals in patients’ own words.
All case managers from participating agencies are trained together on trauma-informed care, implicit bias, customer service, crisis de-escalation, health and system literacy. This builds camaraderie, an understanding of each others’ work, and a common language at a community level.
CASHI teams developed patient leaders as co-designers of their social health integration approach. In this context, 70 percent of CASHI teams implemented approaches to gather patient input. For instance, OHSU Health and VCU Health use
Patient and Family Advisory Councils in which patients evaluate and direct updates on aspects of the program and processes and PROM language to increase patient receptivity.
Participants said they learned a lot about the application of patient-reported outcome measures (PROMs) to social health integration. Some teams using PROMs said they supported better conversations between care teams and patients, consistent with other findings that equity-oriented primary care improves health via improvements in health confidence.
Community Health Workers
In CASHI, community health workers and navigators led improvement efforts. When CASHI teams surveyed patients on their overall experience of working with their CHW or navigator, the average rating was 9.7 out of 10. Yet the CASHI report noted that despite their impact, community health worker burnout is a real problem — it’s very difficult to do this work on the front line, and it’s often undervalued in a variety of ways. Identifying ways for practices/systems to make it more sustainable is going to be critical to longer-term transformation.