Hospitals and Primary Care Practices Need Closer Collaboration With Other Services

Launching effective integrated collaborative care models with supportive technology

Improvements in science, technology, and community care have led to an increase in lifespan. This welcome change in life expectancy brings additional challenges, which include management of co-morbidity and multi-morbidity, increased healthcare needs, and a demand for the delivery of services outside of healthcare settings. A comprehensive multidisciplinary approach may serve patients better.

Care providers working within collaborative care models can target specific patient populations with unique or high needs. These models can involve agency partners from different sectors who agree to work together and provide care to individuals within the community, often targeting complex patient populations. These partnerships, which often include one hospital, utilize some form of a community health model to operate their community care management program.

It is believed that integrated collaborative care models work well for patients with multiple chronic disease conditions, behavioral health or substance abuse needs, and various socioeconomic barriers to good health and care. In community health, action on several determinants (e.g., medical care, health behaviors, social and physical environments) is required. Therefore, no single entity can be held fully accountable for achieving improved outcomes.


Results from Comprehensive Community Needs Assessments Often Indicate a Need for Partnership and Strategy

Non-profit hospitals are required by the Affordable Care Act to conduct community health assessments every three years. Community health needs assessments can include surveys, qualitative interviews and focus groups, concept mapping, health impact assessments, and a review of existing data sources.

Evaluation of the information obtained from these needs assessments often result in the identification of service and care deficiencies within a community or subgroup. These assessments can also be used to inform the selection of partners and a care approach that will provide value-based healthcare to health plan patients and community members. Because social determinants play an integral role in health outcomes and the delivery of care, there is a need to integrate mental and physical healthcare delivery with social services. This may include housing provision, education, physical health promotion, mental health promotion, and advocacy across the lifespan.

One challenge remains — providing care and conducting community outreach requires significant resources, often beyond the capacity of a single hospital and its partners. In community health, outreach efforts are applied broadly and to people who may or may not be receiving health care services at a specific hospital. Even with support from community and government stakeholders, community health partnerships often require additional funding. Partners then negotiate the terms and level of their contributions, but also plan for identifying and applying for funding.

Funding, an Evaluation Plan, and Analysis of Program Data

Once the needs are identified, partnerships will have to determine the level of resources and activities required to meet program objectives. Stakeholder support, beginning with program design and continuing through the evaluation, is critical to a successful community care program.

There is a growing demand for healthcare and social services providers to provide outcomes data using research or program evaluation methods. Philanthropic funding, federal funding, and state and local grants can offer additional support as long as the grantee partnership is prepared to demonstrate change over time. It is essential to track and use data to measure outcomes and identify the impact of the partnership’s interventions.

Implementing a process of collecting data can be very labor intensive, but the benefits are significant. Data collection becomes manageable with the right software since community care approaches often result in better coordinated and more comprehensive care. However, since care increasingly will occur outside of the hospitals, efficient software solutions become more valuable. The results from the effort can inform the development or modification of the care model. Without this evaluation, partnerships may not be eligible to receive additional rounds of funding.


Collaboration Includes Goal Setting and Resource Sharing

Generally, community health partnerships emerge from organizations searching for increased efficiency and competitive advantages. One advantage of a partnership is the ability to share resources that some partners may not have. Technology and software solutions can be costly but are essential to the operations of health and social services agencies. When systems adequately capture data about partnership activities, the collaboration becomes easier to track and manage. Further, the data can be used to demonstrate outcomes to grantors as well as influence health policies aimed at eliminating health inequities or advocating for increased funding.

The challenge with acquiring a single solution is that most software applications are developed for one industry sector. If a partnership consists of a hospital, community mental health clinics, homelessness agencies, and youth and family services agencies, they are likely using different systems and collecting data in a variety of ways. The need for interoperability or flexible software solutions quickly becomes apparent.

Identification of a Software Solution Should Parallel the Design of the Community Care Program

Software that complements the design of the collaborative care program is key, and partnerships are advised to select a solution before launching the community care program. First, a few concepts are important to understand.

Interoperability. This describes the extent to which systems and devices can exchange data, and interpret that shared data. It is defined by the Health Information Management Systems Society (HIMSS) as follows:

Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities.

To appreciate the complexity of interoperability, HIMSS suggests a closer look at the following six dimensions that comprise a more expansive notion of this construct. Interoperability requires:

  1. Uniform movement of healthcare data from one system to another that preserves the clinical or operational purpose and meaning of the data.
  2. Uniform presentation of the data so that disparate stakeholders can use different underlying systems to have consistent presentation of the data.
  3. The contextual information and navigational controls are presented consistently, providing for uniform user controls.
  4. Uniform data security and integrity as data moves from system to system so that only authorized people and programs can view, manipulate, create, or alter the data.
  5. Uniform protection of patient confidentiality even as users across different organizations access data that has been exchanged across systems.
  6. Uniform assurance of a common degree of system service quality so that users can count on the availability and responsiveness of the overall system.

Agile. This refers to an approach to software development that emphasizes incremental delivery, team collaboration, ongoing planning, and continual learning. (See the Agile Manifesto.)

In addition to interoperability, a software solution that is flexible enough to manage large volumes of data originating from disparate sources and different industry sectors is key. Plan to to acquire software and professional technology services that ensure exchange of information between applications inside and outside of the hospital, but also with applications used in other social services sectors.

When out-of-the-box software falls short in meeting a community care program’s needs, software developers that use a time boxed, iterative approach to software delivery may be fitting to the partnership. Agile is building software incrementally from the start of the project instead of trying to deliver it all at once near the end. Agile is a process where analysis, design, coding, and testing are continuous activities. The benefit of this iterative approach is the evolving architecture that accommodates the ability to continuously refine and make changes to the product as the community care program matures. Agile fits well with collaborative care models that involve partners who are pilot testing new community care programs.


Are you considering a community care program? With the right software solution and technology partner, you can efficiently meet the needs of your funders, stakeholders, partners, and patients.

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