There is an emerging consensus in the public health community that the only way to meaningfully impact health outcomes at a community level is to focus outside the traditional definitions of health. Catalyzed by the Robert Wood Johnson Culture of Health prize, the Louisville community has decided to hold itself accountable to looking at health as encompassing more than clinical care and health behaviors, but also the social, economic, and environmental factors that collectively have more impact on the health of individuals.
To successfully address those factors for the community as a whole will require a culture shift - an unprecedented level of coordination across traditional silos of education, workforce development, health care, social services, park systems, the arts community, faith communities, and others. To successfully focus on the needs of individuals across those domains, sharing and layering intersectional data sets and having caring and skilled individuals who can help people navigate the system will be crucial. To do this at scale, both resources and a willingness to disrupt the status quo will be needed.
In order to create a demonstration case that will most dramatically show impact in terms of outcomes and costs, the Community Coordination of Care sub-committee as part of the Louisville Health Advisory Board decided to focus on chronic disease patients and high utilizers of the health care system. Chronic disease patients are faced with specific challenges due to the complexity of the care they need. These issues are often compounded by socio-economic status, geography, mobility, comorbidities, or family/social situation.
As a sub-committee, we have come together to pilot an assertive care model of medical care and disease management needs along with community needs navigation. This is being done by engaging medical staff in tandem with community, volunteers and social care professionals to meet the chronically ill where they are, working to improve health and quality of life, and thus help community members address their essential human needs.
We are engaged in four parallel and interrelated projects:
- Adapting a common screening tool across the community that can be used to identify essential basic needs at multiple entry points into our medical, educational, and social services systems.
- Rallying around a common directory of resources (Metro United Way 211) that can be used to direct people to appropriate services that are convenient to them.
- Establishing a common set of legal agreements that can be the basis for allowing individuals to share appropriate data between organizations to help ensure the best outcomes.
- Structuring our work to take advantage of existing research on impact and ensuring that these demonstration cases, if they have the desired impact, can be used to make the argument for scaling across the community.
What feels powerful about this model is that it is not about bringing additional resources to bear, but rather refocusing how we invest those resources in ways that support individual needs, barriers, and aspirations. We believe that in focusing on the whole person and the whole community, we can make our community a place in which every person can reach his or her full potential.
About the authors: Post written by the Community Coordination of Care sub-committee co-chairs Ben Reno-Weber, Greater Louisville Project; Dr. Fairouz Saad, Louisville Metro Department of Public Health and Wellness; and Tom Walton, Executive in Residence, School of Public Health and Information Sciences, University of Louisville.