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:
  • Identify a potential care delivery partner in the organization. Consider care delivery programs that offer complementary services or that serve some (or all) of the complex needs and high costs individuals in your target population.
  • Engage with the identified partner in the core partnership activities in order to establish alignment between different teams.
  • Establish regular communication to share care management approaches, such as through monthly care management meetings. Consider building care management discussions into existing cross-departmental meetings or other venues, such as grand rounds or brownbag lunch discussions.
  • Consider the detailed descriptions in Recommendation 2 for developing community partnerships, especially those around “As the partnership develops.”
  • Engage senior leaders in the discussion of the value and need for the partnership. Start by inviting senior leaders to join a care coordination meeting. Senior leaders can help clear the path to effective partnership by removing obstacles (such as Information Technology challenges), freeing up staff time to accomplish care coordination, and leveraging resources.
  • Manage potentially competing missions by acknowledging them and focusing action steps on realistic partnership activities.
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:
  • The first step is to identify common needs in the population with complex needs and high costs that are not met by your enhanced care model. These might include access to food, safe housing, legal assistance, child or elder care services, utility and heat assistance, mental health services, substance abuse services, or spiritual or religious supports.
Prioritize an unmet need for intervention:
  • Next, the team reviews the list of common unmet needs and decides on a prioritization method. Prioritization might be based on the level of urgency of the need, or on the number of people affected by the need. An especially effective approach is to learn where your patients with complex needs and high costs present themselves for services — does a significant cohort seek assistance at a food pantry, utility assistance provider, or homeless shelter?
  • A pragmatic approach is to begin partnering with an organization with which the enhanced care team or organization already has a relationship.
Find partners:
  • Once the team has prioritized an unmet need on which to focus, find partners that meet that need. Social workers, community health workers, and peer workers are all well-suited to identifying potential partner organizations. Some patients and families also be a great resource; ask them what organizations or services they’re already using to support their needs. The task is to look for organizations or groups that deliver the needed services. Most communities have many experienced social service organizations and community groups that have served the community for decades. Leverage these organizations’ experience, resources, and skills, whenever possible.
  • Think outside the box for partners such as the police force or fire department. Health Leads enables healthcare providers to prescribe basic resources like food and heat, just as they do medication, and refer patients to the program just as they do any other specialty.
  • If a community organization is a known and trusted resource, and a good proportion of the population with complex needs and high costs participates in their services, partnering with that group could be a boon to the enhanced care model, easing patient recruitment and engagement and bolstering the care plan. A pragmatic approach is to begin partnering with an organization with which the enhanced care team or organization already has a relationship.
Make contact:
  • Once an organization is identified as a potential partner for the enhanced care model, a team member who is skilled in connecting with others contacts to the organization’s program director or senior leader. Request a meeting to learn more about the services provided and to see their work firsthand.
At the first meeting:
  • The primary goal is to listen and learn about the other organization and the services they provide.
  • Identify how their work impacts the social determinants of health, and express how crucial their work is to the population with complex needs and high costs.
  • Discuss ways in which engaging individuals in the enhanced care model could bolster the partner organization’s intended outcomes.
  • Explore whether the organization has interest to try out some early collaboration approaches, perhaps focusing on referral methods or partnering to try to improve service and care delivery for a few people in the target population.
  • An ideal first meeting ends by outlining collaborative next steps that will be accomplished in a specific and relatively short timeframe, noting completion dates and responsible parties. For example, one colleague will refer two patients to a colleague of a different organization by the end of next week.
Early partnership activities:
  • Learn about the requirements around sharing personal health information with the partner organization. In the United States, compliance with the Health Insurance and Accountability Act (HIPAA) sets parameters around sharing patient information. Each partner’s representative can contact their organization’s legal counsel to learn more about the organization’s approach to protecting health information.
  • Develop methods to share information while complying with HIPAA. This will usually involve patients signing authorization to share certain categories of information with a specified organization. Large-scale data sharing agreements may also be explored, but note that establishing such agreements requires a significant amount of time and legal counsel.
  • Consider ways of partnering that comply with HIPAA and allow care managers to practice collaborative care coordination. Consider case conferencing about a patient vignette rather than a specific patient.
As the partnership develops:
  • Foster a direct partnership between enhanced care model care managers and similar staff in the partner organization.
    • Make sure that care managers and their peers in other organizations meet in person to learn about how each other supports patients with complex needs and high costs.
  • Ensure consistent collaboration between two levels of staff at each organization: director-level leadership and care managers.
    • Encourage and supervise care managers and their equivalents to maintain open and consistent communication to identify and resolve patient-level needs and challenges, including inefficiencies in cross-organization referral or collaboration methods.
    • Ensure that program directors cultivate and maintain open and consistent communication to address challenges or problems as they arise, with frequent cross-organization huddles at the leadership level. The occasional friendly lunch or coffee meeting can also strengthen the partnership, transparency, and open communication.
  • Be strategic about case conferences, where program leaders and care managers from both organizations raise person-specific challenges and problem-solve in real time.
    • Where HIPAA compliance poses limitations, consider hosting case conferences that focus on anonymous patient vignettes to offer opportunities for real-time problem solving and training while eliminating the need to share personal health information.
    • Use case conferences to cultivate relationships between the two organizations, celebrate successes, identify duplication in services, leverage resources, coordinate care and outreach efforts, and share aggregate outcomes data.
    • Standardize and scale up effective care delivery methods. At each organization, develop ongoing feedback loops between care managers and directors to surface challenges and successes, develop standard operating procedures, and shape potential advocacy efforts.
    • Invite decision makers to observe firsthand the challenges facing care teams in delivering care, if patient privacy allows.
    • Leverage local health and social service leaders who can broker high-level partnerships with other local leaders (e.g., government, philanthropy, social service providers, housing organizations, hospitals).
Partnerships and collaboration takes many forms, for example:
  • A religious leader, working in partnership with a care team, may spend a small amount of time during services to talk about the connection between spiritual well-being and health, and can follow up the service by sharing information on local resources that support families’ health needs.
  • A health clinic may refer the family of a child with asthma to a paralegal services team, who contact the landlord of their apartment to fix building code violations thought to be exacerbating the child’s condition.
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:
  • Search for existing groups before beginning the process of convening multiple potential partners, as it may be possible to join the existing group and carry out the large-scale partnership activities through the existing coalition structure. Similarly, some of the partnership activities may have already been accomplished by the existing coalition.
Early-stage activities for large-scale partnerships:
  • Work together to catalog the community’s assets using specific asset-mapping tools.
    • Draw on the expertise of local community leaders to add informal assets to the map. Consider that certain support groups and neighborhood watch groups provide significant support to the community, but may not be visible from the sidewalk or in the phone book. Learn about the ways that each organization or group serves the community.
    • Learn about asset-based community development.
    • Consider using a visual display of the social determinants of health and invite each partner to indicate all the social determinant area(s) their organization impacts. sdoh_rainbow
  • Review existing community data sets to look for subpopulations of people with complex needs and high costs. Is there overlap with the people identified as potential patients with complex needs and high costs?
    • Police, fire department, and emergency medical services all collect data related to health determinants, with some data on health outcomes, as do local governments, particularly public health and vital records departments.
    • Other potential sources of data are social service organizations, shelters, and food banks.
  • Identify local trusted leaders and explore ways to partner with them.
    • These are individuals who have the trust of the community and may be seen as an “unofficial mayors;” local people may seek out these local leaders for guidance or to help resolve disputes.
    • Community organizers and long-term community groups will know such trusted leaders and be able to invite them to discuss opportunities to partner with the enhanced care team.
  • With all partners, develop a shared vision for the community and/or those each partner serves.
    • The vision outlines the coalition’s purpose, such as “Making Pueblo County the healthiest county in Colorado.”
    • An effective vision statement is easy to understand, can be communicated to anyone in the community, and is broad enough that many diverse stakeholders, partners, and people identify their role in the shared work of achieving the vision.
As the coalition develops:
  • Develop a neutral convener role that will support the development of a shared goal, alignment of coalition efforts, collection and analysis of shared data, collaborative funding efforts, and ongoing development of the coalition.
  • Develop a shared aim with all partners, or periodically refine an existing shared aim.
    • The aim specifies targeted outcomes and names a deadline (“how much, by when”), such as “We will reduce unnecessary hospitalizations by 30% by December 31, 2018.” A community coalition in Pueblo County, Colorado used ReThink Health as a way to envision a future to work towards together.
    • An effective aim statement engenders accountability for the shared work, which is a powerful motivator, and clearly demonstrates the value of the coalition’s efforts to the community.
  • Identify interventions that lead toward achieving the shared aim, and then carry out the interventions in partnership with coalition members.
    • Begin by testing one activity, such as co-hosting a community event, introducing a wellness survey at a planned neighborhood festival, or including health screening at a community event.
    • Develop early collaborative efforts into co-designed work processes to frame ongoing efforts at each organization. Collaborative approaches will grow over time; leaders must be disciplined about developing work processes to ensure durability of the partnership and consistency of collaborative efforts.
  • Analyze stakeholder positions and potential contributions, both positive and negative.
    • The neutral convening organization can hold a strategic meeting every three to six months to list and assess the level of support, or lack of support, from each stakeholder group. Make sure to note immediate action steps to align stakeholders and neutralize opposition.
  • Explore collaborative funding approaches.
    • Start by supporting each other’s funding efforts by writing letters of support for grant funding.
    • Develop ways to pool resources. Consider shared savings arrangements that allow partners to recoup savings from reductions in expected high-cost health care utilization.
    • Consider direct contracting arrangements between partners to allow collaboration to grow in scale.
  • Develop a shared goal to align all partners’ efforts.
    • Co-create the shared goal over time and in ways that invite participation to foster shared ownership. This, in turn, supports different stakeholders’ dedication to the goal and their inherent desire to accomplish the goal.
    • Start by having a conversation among stakeholders about what brings each of them to the table and what each partner aspires to achieve for the community.
  • Determine shared decision-making methods.
    • A coalition of multiple stakeholders will likely include many partners who have no hierarchical “pull” over each other’s activities. With limited defined leadership at the coalition level, a defined decision-making process is important to structure the ways partners interact with each other in pursuit of shared goals. For example, the coalition may designate a specific person as a tie-breaking decision-maker; launch a small committee tasked with making decisions on topics for which the larger group reaches a stalemate; or develop rigorous discipline around coming to key decisions during scheduled meetings times, relying on those in the room to represent the entire group.
  • Develop methods of sharing data among partners.
    • With the development of a shared goal, the coalition will need to define a small set of process and outcome measures to understand whether efforts are leading to the desired impact.
    • Begin by discussing data that each partner currently collects, and consider how to share that data.
  • Celebrate successes, however small in scale.
    • Most regional health coalitions work toward long-term goals, with expected outcomes years in the future. This underscores the importance of identifying shorter-term successes, which can be shared with others through data on process measures, case studies, or even anecdotes. Explore powerful visual statements of short-term successes, such as images of the number of people engaging in physical activity or living in safe housing.
    • Consider recognizing improvements in processes such as new examples of collaboration, community event attendance, or local participation in certain health-promoting activities.
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.