Community connections: Developing effective community partnerships to meet patient-centered goals in the health care home

Coordinating patient-centered care in Health Care Homes (HCH) requires not only ambulatory care redesign but also realignment between health care delivery systems and community service providers. Most healthcare systems do not connect with community resources beyond referral leading to under-utilization of services, fragmentation of care and poor health outcomes.

Purpose: To develop and evaluate effective partnerships among patients/families, health care homes and community service providers (Community Connections) to enhance care coordination with a HCH using a 3 month Community Care Team intervention. Aim 1: Evaluate team cohesion and collaboration among Community Connections partners; Aim 2: Evaluate the effect of Community Connections on patient health outcomes (physical, emotional, social), care coordination and self-management support, and use of services (health care and community) compared to usual care.

Methods: A randomized, control trial design was used. The sample included 60 adults age 55 and older with multiple chronic conditions and their support persons from a Midwest HCH ambulatory care setting with randomization to intervention or usual care groups. The intervention, based on the Wraparound Process and guided by the Chronic Care Model, included a Community Care Team comprised of HCH nurse care coordinator, two community service representatives, and patient/support persons. Team meetings conducted at baseline where a strengths-based assessment, an Action Plan based on patient priorities and a follow-up strategy were developed. All members left with a copy of the Action Plan indicating who was responsible for each action with a completion date. Nurse care coordinators connected with patient/support persons and shared progress with Community Care Team members during and at completion of the 3 month intervention. Team meetings were monitored and evaluated using the Team Meeting Observation Form to assure intervention fidelity. Qualitative data from interviews/focus groups and team and patient quantitative data collected at baseline and at 3 months were merged to address study aims.

Findings: Preliminary data suggest high levels of team cohesion and collaboration and positive effects on care coordination and self-management. Data collection and analysis will be complete June, 2012.

Conclusion: Findings may inform ambulatory care models and realignment strategies between health care homes and community service providers to meet patient-centered goals.