Community Care Coordination at a Glance | AHRQ Innovations Exchange

Community Care Coordination at a Glance | AHRQ Innovations Exchange



Community Care Coordination at a Glance

Introduction

The Community Care Coordination at a Glance page features programs that have implemented models of care that integrate various health and social support services within a community. Community care coordination builds upon the American Academy of Pediatrics’ recommendation to improve quality of care by coordinating needed health and social services.¹ This collaboration of community resources aims to improve the health of individuals, particularly those from vulnerable populations, by alleviating both medical and social barriers to care, including employment, housing, and transportation.

Innovations Addressing Community Care Coordination

In March 2008, the Community Care Coordination Learning Network (CCCLN) was launched with a focus on the Pathways Model of community care coordination, which was created by Drs. Mark and Sarah Redding of Mansfield, Ohio. Similar to the general purposes of other AHRQ-sponsored communities of practice and learning networks, the CCCLN provided learning and networking opportunities among the AHRQ Health Care Innovations Exchange users.

During its tenure, the CCCLN was a valuable resource for:

• Connecting potential adopters of the Pathways Model;
• Facilitating the exchange of information and translation of knowledge through presentations, group meetings, standard data collection and reporting efforts, and product development activities;
• Fostering networking and learning about issues affecting community care coordination and its effect on vulnerable populations, whom are considered high risk for chronic health conditions; and
• Developing community-based strategies designed to identify at-risk populations within local communities, create pathways that link these populations to health care and social services, and measure outcomes.

The CCCLN originated with its champions – Drs. Mark and Sarah Redding – and grew to a network consisting of 17 hub directors, representing 16 distinct community hubs in 10 states. As the network evolved, members engaged in community-based participatory research activities and developed work products such as a guide that provides a step-by-step process to build and sustain an infrastructure to support the delivery of community care coordination services.

In September 2011, the CCCLN transitioned from an AHRQ Health Care Innovations Exchange-sponsored learning network to the National Center on Community Care Coordination in the Rockville Institute for the Advancement of Social Science Research. 

Please visit Community Care Coordination at a Glance for regular updates regarding programs and quality tools.

Innovation Profiles

• Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes
• Teams of Diabetes Educators Regularly Visit Rural Clinics to Coach African-American Patients, Leading to Better Glycemic Control and Potential Cost Savings
• Alliance Creates Community Health Workers’ Scope of Practice, Training Curriculum, Certificate Program, and Reimbursement Strategy, Expanding Their Integration Into the Health System to Reduce Health Disparities
• Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

More Community Care Coordination Innovations >>

QualityTools

• Care Coordination Measures Atlas
• Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways
• Pathways: Building a Community Outcome Production Model

More Community Care Coordination QualityTools >>

Additional Resources and References

1. Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs American Academy of Pediatrics: Committee on Children With Disabilities 1999 http://pediatrics.aappublications.org/content/104/4/978.full  (Adobe Reader is required to view or print the PDF. Download a free copy here. )