Children - Key Activity 15

KEY ACTIVITY #15:

Strengthen Community Partnerships

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; address social needs.

Overview

Strengthening partnerships with community-based organizations that share the practice’s vision and goals for their patient population enables the practice to provide more holistic care to patients and leverage many of the strengths and resources available in the community. These partners provide various services and programs to the community, such as education, housing, food, transportation, employment and social support.

This activity provides considerations and tips for strengthening partnerships, although note that deep engagement in this work can require significant resources from your practice.

Action steps and roles

1. Start by understanding the resources and partnerships available through Medi-Cal.

Suggested team member(s) responsible: Clinic operations and leadership staff who will liaise with community partners.

Resources include supports that are available to all Medi-Cal patients, such as transportation to medical appointments, as well as Medi-Cal Community Supports for eligible individuals with higher levels of social needs. The following is a list of social support resources that are available to Medi-Cal patients when eligibility criteria are met.

• Transportation to medical and other Medi-Cal-covered appointments.
• In-home supportive services, such as personal home care assistance for those who qualify.
• Community-based adult services, such as day programs outside the home for individuals who need assistance with activities of daily living.

For individuals with the highest needs, the 14 Medi-Cal Community Supports are:

• Housing transition navigation services.
• Housing deposits.
• Housing tenancy and sustaining services.
• Short-term post-hospitalization housing.
• Recuperative care (medical respite).
• Day habilitation programs.
• Caregiver respite services.
• Nursing facility transition or diversion to assisted living facilities.
• Community transition services or nursing facility transition to a home.
• Personal care and homemaker services.
• Environmental accessibility adaptations (home modifications).
• Medically supportive food and meals or medically tailored meals.
• Sobering centers.
• Asthma remediation.

For specific providers in your area, contact the provider services department of your Medi-Cal managed care plan to learn more about the providers of these services. With a list of contracted community-based organizations, your practice can start to build relationships and support ongoing social needs for your patients.

For an overview, DHCS has provided information about the current state of Enhanced Care Management and Medi-Cal Community Supports in the Community Supports Year 1 Summary and the Enhanced Care Management Year 1 Summary.

2. Complete an environmental scan to understand who your patients identify as trusted messengers and resources in their community.

Suggested team member(s) responsible: Health center leadership, community health workers, care coordination staff.

This can be completed by interviewing patients and families, especially with the assistance of community health workers as adept listeners. Confirm existing partner relationships. After that, a stakeholder map and community profile of key current and prospective partners can be developed.

For pediatric populations, key community partners include schools, libraries, child welfare agencies, food assistance programs, and community-based programs (e.g., early literacy, youth activities).

3. Convene partners as a work group to develop strategies and interventions to address health-related social needs.

Suggested team member(s) responsible: Health center leadership.

In some cases, your practice may serve as a convener, bringing partners together for collaboration to avoid relying on individual relationships with external organizations. Be clear on your asks and offers to ensure the relationship will be mutually beneficial.

Develop a shared aim statement with your partners as to why this work is important and your vision of what you hope to achieve. Following the aim statement and formalize your structure and system of collaboration accountability for progress in the form of ongoing pacing of meetings on a regular basis rather than relying on transactional relationships.

To ensure proper understanding of expectations, roles and commitments, memorandums of understanding should be developed. Of note, California has data-sharing requirements for clinics and community-based organizations that help with referrals, coordination and data-sharing. Some organizations will be required to share data through the California Data Exchange Framework (DxF) starting in January 2024.

4. Collaborate with your partners to co-develop and deliver on a shared set of strategies on a community approach to address health-related social needs.

Suggested team member(s) responsible: Health center leadership.

The practice should benchmark and collate approaches to identify potential interventions for addressing health-related social needs. Developing a driver diagram can help guide your efforts and to set priorities. Leverage CalAIM resources as part of your intervention plans.

Use workflow mapping tools, swim lane diagrams and checklists that clarify roles and plan initiatives. This allows for the practice to develop clear action plans clarifying leaders of intervention strategies, timetables and measures of progress and success.