1. Strengthen partnerships within your organization to create opportunities for greater integration and leverage of existing resources.
  2. Strengthen community partnerships to meet the needs and enhance the strengths of the population with complex needs and high costs.

1. Strengthen partnerships within your organization to create opportunities for greater integration and leverage of existing resources.

Engage information technology, finance, and senior leaders as partners to ensure that the enhanced care team has timely access to information, sufficient resources, and management support.

Some organizations have various departments providing clinical care that can support the chosen population. Others may have colleagues providing care management through other internal programs (e.g., home visiting, care management with subpopulations such as those living with HIV/AIDS). Partnering with these colleagues is relatively simple in terms of the ease of internal information sharing about individual patients in the target population.

Enhanced care models that do not directly incorporate a primary care physician on the care team will deploy partnership methods with patients’ primary care physicians, whether the physician provides ongoing care or patient referrals.

Deploying partnership methods:
Tips and guidance for strengthening partnerships within your organization:
  • Consider existing meetings or other venues to bring care coordination discussions to a broader group, beyond the enhanced care team.
  • Senior leadership support will assist the team in forging cross-departmental partnerships.
  • Be clear about your enhanced care program’s purpose, benefits to patients, and how it is complementary to other existing programs.


“We try really hard not to be siloed. We collaborate with many other clinicians and programs, whether they’re within our organization, like cardiologists or inpatient doctors or the asthma nurse specialist, or whether they’re from community-based organizations, such as the Institute on Aging or a local organization that supports caregivers.”Elizabeth Davis, MD, Medical Director of Care Coordination, San Francisco Health Network Primary Care

2. Strengthen community partnerships to meet the needs and enhance the strengths of the population with complex needs and high costs.

There is a range of efforts that can be described as partnerships that support the enhanced care model for individuals with complex needs and high costs. Some groups will start small, developing ways to refer individuals in the chosen population between two organizations. Others will engage in broader partnership efforts, developing a shared aim for a specific population with a targeted scope of work, collaborating around problem solving — often through collaborative case conferences — and sharing data.

Many health care and social service organizations start small with referrals between two organizations, then build a richer partnership together. Some enhanced care models will find that a coalition approach is the most effective way to serve the target population’s array of needs. Most health care organizations have little scope to address the social determinants of health and must partner with existing community resources to support these needs. Social determinants of health are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” Below, we describe small-scale partnerships and large-scale partnerships.

Developing a small-scale partnership, step by step:
Identify unmet needs that are outside the scope of the enhanced care model:
Prioritize an unmet need for intervention:
Find partners:
Make contact:
At the first meeting:
Early partnership activities:
As the partnership develops:
Partnerships and collaboration takes many forms, for example:
Developing a large-scale partnership using a regional health improvement approach:

Community coalitions have been active for decades in some areas, usually with the aim of improving health, wellness, or quality of life outcomes in a region. The first step in exploring a coalition approach is to look for existing coalitions. Understand that existing community coalitions have an established mission, vision, and roster of collaborative activities. It is very important to learn the coalition’s culture and diplomatically navigate potential partnerships focused on individuals with complex needs and high costs. Enhanced care model teams that seek a place at the coalition’s table must be willing and able to negotiate existing partnerships, and to creatively find opportunities to fold in collaborative approaches to serve their chosen population segment.

A common structure is a recurring community meeting or roundtable that regularly convenes multiple stakeholders. Other groups will have well-established coalitions with governance structures in place. Community partners often include the Chamber of Commerce, neighborhood watch groups, community-based organizations such as Boys’ and Girls’ Clubs and YMCAs, religiously affiliated charities, and mental health organizations.

Identify existing coalitions and seek ways to collaborate:
Early-stage activities for large-scale partnerships:
As the coalition develops:
Tips and guidance for strengthening community partnerships:
  • Be realistic about the capacity of your organization to meet the non-health-care needs of the target population. For services such as housing, shelter, religious guidance, or access to food, external partnerships are typically the most efficient way to support patients’ needs.
  • Get clarity on the capacity of partner organizations and plan accordingly. If a partner can serve only a portion of the population with complex needs and high costs, consider funding opportunities to help the partner organization expand or search for other partners to serve the next cohort.
  • Develop the discipline that decisions will be made by those who show up to meetings, rather than waiting for a session with 100 percent meeting attendance.
  • Recognize that any coalition is inherently weak. It is instructive to consider that a coalition is in the process of crumbling from the moment it is convened. Considerable time and effort will need to be spent cultivating existing partnerships, growing collaboration opportunities, and seeking out interested new partners. Celebration of successes is helpful here, as well as the opening of frank conversations about concerns and failures.
  • Learn about asset-based community development.
  • Learn about collective impact methods.