Health Affairs Blog
GrantWatchWorking Across Sectors To Improve Health For Older People: The Community Care Connections Program
Experts estimate that up to 80 percent of a person’s health is determined by nonclinical factors—things like financial stability, access to safe, affordable housing and to healthy food, and social supports. Yet, as a society, we spend billions of dollars providing clinical care that often fails to effectively address the social, economic, and environmental factors that impact health.
Community-based services—rather than clinical services—offer support around these broader health determinants and often become particularly important as people age. Services such as transportation, meal preparation, socialization programs, housekeeping, and counseling on financial benefits can support older adults in maintaining their independence, managing chronic health conditions, and preserving their quality of life.
Ongoing federal and state health reform initiatives—including Accountable Health Communities, State Innovation Models, and New York State’s Delivery System Reform Incentive Payment (DSRIP) Program—aim to improve the integration of social services and medical care and reduce reliance on hospital-based services. Despite significant investments, these large-scale initiatives have not resulted in a reliable and straightforward method of breaking down silos and aligning existing systems.
CCC: A Promising Approach
The Robert Wood Johnson Foundation funded the Systems for Action research program to “test new ways of connecting the nation’s fragmented medical, social, and public health systems.” A Systems for Action grant enabled researchers at New York University (NYU) and the New York Academy of Medicine (NYAM) to investigate the impact of Community Care Connections (CCC), a program developed and implemented by Lifespan of Greater Rochester, a community-based aging services provider located in Rochester, New York, which aims to integrate social services into medical systems of care to meet the triple aim of improved patient experience, better patient health, and lower health care costs.
Lifespan’s CCC program takes advantage of the fact that older adults interact regularly with the medical system, and it uses these clinical encounters to link patients to resources that address nonclinical health determinants. When a provider sees a patient (over age 60) who is overusing emergency or hospital-based medical care, or who is struggling with a nonclinical issue that affects his or her health (for example, housing or food insecurity), they make a referral to CCC. Lifespan’s social work case managers then reach out to the patient to schedule a home visit and assessment, create a care plan, link the person to appropriate services, and follow up as needed. Patients receive additional support from nurse care managers who assist patients later on in maintaining their health and navigating the health care system by, for example, managing appointments and attending them with patients, setting up transportation, conducting medication reconciliation, and communicating with clinicians.
NYU and NYAM researchers conducted a mixed-method evaluation of CCC to examine (1) pre-post differences in rates of emergency department (ED) visits and inpatient hospitalizations and (2) how the project affected fragmentation and alignment of social service and medical systems.
We found that, from 2016 to 2019, 1,225 CCC participants were referred to an average of four different types of services. Participants in the program experienced a 28 percent reduction in visits to the ED, a 29 percent reduction in inpatient hospitalizations, and a 23 percent reduction in observation stays in the 90 days after initiating program participation, compared to the 90 days before participation.
What Makes The CCC Program Work?
There are many programs that claim to link patients to social services, begging the question—why does the CCC program work? What are the key components of the CCC program that make it a success?
We explored these questions in more than two dozen interviews with health care providers, social services providers, Lifespan staff, and clients and discovered three key areas in which the CCC program addresses common medical system shortfalls.
(1) The CCC program offers providers and patients a central, trusted point of contact for addressing nonclinical health issues.
Navigating complex systems—medical, social, or other—can be difficult for anyone. Both patients and providers reported that before working with Lifespan, they were unaware of many of the resources available to assist with nonclinical health issues. They also noted that, even when they knew there might be services available, investigating and managing the referral process to multiple organizations and programs to address the myriad needs was a challenge for any person.
The CCC program offers both patients and providers a central point of contact that assists with navigating both health and social systems. Rather than a primary care provider spending hours trying to learn about, contact, and complete referrals to multiple organizations, they refer patients to Lifespan—a long-trusted community partner—and feel confident that the needs of their patients are being addressed. Similarly, patients have a trusted person, dedicated to them, whom they can call for support on a range of needs, without having to do research themselves.
(2) The CCC program closes communication gaps.
Patients, providers, and Lifespan staff described multiple ways that the CCC program contributes to improved communication with patients and across care settings.
- CCC facilitates communication with patients by enabling case managers and care coordinators to establish rapport, and build a trusting, supportive relationship, with patients. This relationship enables patients to reach out regularly and share concerns with CCC staff that they may not otherwise report.
- CCC facilitates communication between social services programs and providers by “closing the referral loop” and following up with medical providers after intake and when there are case updates, enabling clinical providers to work with a more complete picture of their patients’ situation.
- CCC staff members facilitate communication between patients and their medical providers through care coordination. Nurses attend appointments with clients and assist them with adhering to instructions and prescribed treatments.
(3) The CCC program offers Lifespan staff the time and flexibility to provide holistic and comprehensive care to patients.
The nature of the CCC program enables case managers and care coordinators to develop and implement a comprehensive and holistic care plan that takes into account the strengths, challenges, and resources of patients. These care plans are developed as a result of at least one home visit (if not more) and an in-depth intake assessment that can last up to one and a half hours. Care plans often incorporate medical services, community-based services, and support from caregivers.
Time and financial constraints mean that even the most dedicated medical providers rarely have the resources to engage in such detailed and comprehensive care planning. As a result, they are often operating with an incomplete understanding of the social, economic, or environmental issues that patients face, all of which impact the ability of their patients to adhere to treatment recommendations and manage their health. By filling in the blanks for providers, the CCC program helps to address pressing needs and enables providers to recommend treatment options that take into account the personal capacity and resources of patients.
Conclusions
CCC offers a promising model for integrating social and medical services while also addressing common challenges that patients and providers face when trying to navigate medical care systems. By using the primary care setting as a point of entry for social services while relying on the pre-existing expertise of community-based service providers, the program improves patient well-being and closes gaps in patient care, without adding to the ever-increasing burdens placed on primary care providers.
Editor’s note: Watch for the April 2020 issue of Health Affairs, which is a thematic issue on integration of health and social services.
