Let’s face it: we’re not short on frameworks in healthcare lately! More specifically, the field of social determinants of health and essential needs initiatives has exploded in the past 4-5 years, with an ever-expanding suite of frames and roadmaps to match. While this rapid increase in stakeholder contributions is encouraging, we ultimately need to be better connected to each other to realize the full potential of the field — both to build off our peers’ successful efforts and to keep pace with the rapid learning that is underway.
That’s why I was excited to join the Center for Health Care Strategies and National Center for Complex Health & Social Needs as they introduced the new Blueprint for Complex Care. Because if those of us who work hard to transform care models are better integrated with each other, then those care models can be better integrated as well — which is ultimately what matters for the people and communities we serve.
Across social, behavioral and medical care domains, we often hear of challenges that are rooted in siloed initiatives. These silos exist even within otherwise-aligned social health initiatives (e.g. “these patients are Accountable Health Communities patients; those patients are Health Leads patients”). To deliver whole-person care we need to move beyond siloed thinking and do a better job coordinating these efforts — and the Blueprint helps to address this challenge as a field-building effort.
Specifcally, the Blueprint offers 11 core opportunities to strengthen the field of complex care. And while all are solid recommendations, a few really stand out to me:
1. The field must further develop quality measures.
For the past year, Health Leads and our partners in the Collaborative to Advance Social Health Innovation (CASHI) have tested new ways to measure patient-reported health and well-being — and understand linkages to essential resource navigation in the process. This is an ongoing learning effort, and if we collectively identify better measures as the Blueprint recommends, then we all can invest more energy in making the changes that are most meaningful to the people we serve.
2. We need to advance core competencies alongside supportive training and resources.
What I appreciate within this recommendation is an explicit call to convene front-line staff doing this work. All too often, well-meaning stakeholders in health take action without the right voices at the table. We recently adjusted one of our programs aimed at capacity-building for teams of Community Health Workers, based on their input. We needed to hone in on things like case support, as well as maintaining compassionate boundaries to manage the stress that comes from working with individuals for whom our systems are failing. So we listened and responded — and had more meaningful impact as a result. We are committed to continuing to be responsive to the needs of front-line staff and the people they serve as our north star for improving health.
3. Most importantly, we must value and prioritize the leadership of people with lived experience
Asking people to help design and improve the care that is meant to meet their needs just makes sense. We have partners that are implementing a range of ways to engage consumers — listening circles and focus groups, patient experience mapping, improving Patient Advisory Councils, making patients members of improvement teams, and more. Ultimately this leads to better workflows, better language, more patient-centered measures, and more common sense. Simple questions tend to surface, like “Before you test that change, did you ask your patients what they think?” This happens in other industries as standard practice, and it needs to be the standard for ours too if we want a shot at improving health in this country.
Our Chief Clinical Officer, Damon Francis, often reminds us: “Patients come integrated. Their care needs to be!” By its nature, the Blueprint for Complex Care supports this by spanning clinical, behavioral and social care domains. In addition to its (solid!) recommendations for building a field that delivers better health, Health Leads is excited to collaborate within this effort of passionate stakeholders working to develop less fragmented and higher impact care models across the country.
Download the Full Complex Care Blueprint