Healthy Northeast: Community-based Care Coordination to improve physical and mental health

Community Solutions (CS) facilitates a neighborhood-wide development initiative to improve the physical and mental health of residents living in an underserved neighborhood of a mid-size American city. This collaborative effort addresses multiple social determinants of health: crumbling municipal infrastructure, diverse but disconnected services, and limited access to health care. The neighborhood has the highest rate of emergency room use in the city, with disproportionately high rates of chronic physical and mental illnesses. Access to primary care and mental health care, as well as social services, is limited. Located in the neighborhood, however, is a former factory site that serves as the engine of community revitalization and serves as the community hub where neighborhood outreach services can be anchored. One component of these outreach services is evidence-based care coordination for residents who frequently visit the emergency room. Our individualized, strengths-based approach transforms residents' experience of the care system toward the goal of whole health care. The poster will present the CS care coordination model and provide examples of how care coordinators working within this neighborhood revitalization context achieve improved access for residents to physical and mental health services.