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Is Your Organization Engaged in Care Delivery On its Own? Not Wise!

Hillary Rodham Clinton once said, “It takes a village to raise a child.” Mounting evidence of effective healthcare delivery strategies supports the notion that it takes a community to manage high-risk patient populations. Literature related to healthcare reform and underserved patient populations abounds with case histories of community-based efforts leading to significantly improved treatment utilization, reduced costs of healthcare delivery and a better quality of life for many. Proponents of building “a community of health,” including organizations such as the Health Research and Educational Trust, and the American Hospital Association and Hospitals In Pursuit of Excellence, point to collaborative community opportunities for healthcare providers.

Opportunities exist for healthcare providers and healthcare systems to partner with communities in a collaborative effort that can add resources, expand community reach, target high-priority risks, and develop more effective interventions toward meeting the goal of delivering better healthcare throughout the community in a more cost-effective manner. Community partnering and active engagement opportunities for effective management of high-risk populations are many. This article reviews those opportunities and the types of engagements that can prove beneficial to healthcare providers and the populations they serve.

State health agencies provide a wealth of resources. For example, systematic data collections and analyses regularly provide insight into population health conditions, clinical performance data, and evidenced-based recommendations for healthcare practice improvements. State agencies typically play an active role in health promotion and disease prevention, which can expand providers’ reach into communities, including high-risk populations. State agencies are instrumental in establishing policies and procedures, and they offer the opportunity for cooperative efforts in establishing standards for certification programs and clinical guidelines. States are faced with the challenge of providing more comprehensive health services to their population while reducing costs. Governors and legislators are often viewed as the source of funding for new programs designed to meet improved healthcare goals.

In-system providers such as home health, preventative care, community clinics and post-acute intervention organizations provide additional resources that can make primary care far more accessible to high-risk patients. Opportunities exist for information exchange, coordinated care, in-community outreach, patient education, and risk assessments; all of which may help decrease emergency department visits and hospital readmissions and contribute to improved outcomes at reduced expenditures. Collaborations with local public health agencies provide an opportunity to assess the local community health needs and risks. Analyses of the data collected from assessments can yield categorization, prioritization, and intervention strategies that target community health threats.

Organizations that serve the community—municipal agencies, community health centers, charitable organizations, schools, and faith-based organizations—when mobilized through common goals, priorities and intervention strategies can greatly increase capacities for information collection and sharing, outreach, and educational efforts.

Insurance payers and local industry, with vested financial interests in community health, represent the potential for the establishment of company wellness plans and employee incentives for healthy behavior as well as capital investment to support healthcare initiatives.

Given their existing connection with the local community, healthcare providers are in a unique position to provide leadership in the development of a community of health. Executives who work more closely with community leadership can take the lead on initiatives by sharing community health data and health concerns, by helping to establish a shared vision and mission for community health, by designing joint intervention strategies, and by providing facilities for community meetings and focus groups.

The outcome of collaborative ventures and local partnerships can fortify efforts to improve medical outcomes and curb rising costs of care delivery through a community of health that establishes a greater community presence for providers and delivers better access to care and more comprehensive care to high-risk populations.

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