Rebounding from COVID-19: How whole-person healthcare hubs can guide the way

by Gary Hirsch and Kate Isaacs - 3 min. read - (reviewed 2020-07-27:0027 PDT)

America’s economic and racial inequality1, thin social safety nets and fragmented2 health care system are putting the most disadvantaged vulnerable people at the greatest risk3 from COVID-19. Yet, in the midst of this crisis, there are inspiring examples of organizations that are transforming health care through trust-based relationships and community partnerships that provide whole-person care for people’s physical, economic and social needs.

The pioneering research of forest ecologist Dr. Suzanne Simard4 offers a metaphor for what these health care organizations do. Trees, it turns out, are in constant relationship with each other via large underground networks5 through which they communicate and share essential nutrients. The large hub, or “mother,” trees6 anchor the health of the forest, supporting other trees’ growth and their quick recovery after stress and disease.

Right now, some health care groups are acting like hub trees to enable resilient community health. Structured as Accountable Care Organizations7 (ACOs) or Accountable Communities of Health8 (ACH’s), these organizations offer an alternative to the dominant system of health care, which depends on maximizing the volume of medical services. Instead, ACOs and ACHs aim to improve their patients’ overall health outpid031-unnecessary-catastrophe-US-hospitals-health-care-heroes-ehirsch-articleform relationships with patients and other community organizations, connecting diverse parts of the local health care ecosystem to coordinate care for patients’ diverse needs. 

Whole person care relies on empathetic relationships with patients to understand a wide range of factors that influence people’s lives. The Camden Coalition9 in Camden, New Jersey is an ACO-like partnership that is well known nationally for using integrated care to prioritize health services for people with complex health problems. The coalition’s goal is to build authentic healing relationships10 with people to help them realize their highest level of health and wellbeing.

To do this, a frontline team of “Patient Navigators” functions like the roots of a hub tree to support patients in the health care network. Responding to the pandemic crisis, Patient Navigators expanded Camden’s social determinants of health screening to all members being tested for COVID-19. Navigators survey people to find out how the Camden Coalition can best offer whole person care by asking how they are doing physically and mentally, inquiring as to their necessities (food, housing, utilities, social connection and personal safety) and whether they have access to the necessary resources. The Navigator then connects the member to community organizations that provide housing, food programs, legal help and other services. The coalition makes daily calls to those partners to get up-to-date information on their operations and capacity. The patient’s information is sent to Camden’s Health Information Exchange11, which centralizes real-time patient data from a variety of sources and flags patients for follow-up care. The coalition is also taking steps to ensure equitable access to care, for instance providing iPads to a local homeless shelter for telehealth appointments and working with other municipal and state agencies to overcome racial health inequities12. Its partners include Camden’s Police Department, which is regarded as a national model13 for progressive policing.

HealthierHere,14 an ACH in the Seattle region, is playing a similar hub tree role on the other side of the country. In 2018 HealthierHere launched an effort to improve health equity and outcomes via a Consumer Voice Listening Project15 that engaged 34 community organizations and nearly 3,000 community respondents from 40 surrounding communities. Through this initiative, HealthierHere developed a solid grasp of community needs and cultivated an extensive network of relationships with partner organizations that undergird its COVID-19 hub activities in the local and state health care ecosystem.

As the COVID-19 crisis accelerated, HealthierHere quickly assembled a Resource Hub16 to assist its clinical and community partners to adapt their practices and connect with local resources. It launched an early telehealth initiative and then helped to create a statewide infrastructure for future telehealth care. HealthierHere also accelerated the implementation of a Community Information Exchange17 (CIE), a network of cross-sector partners who coordinate to ensure that individuals have better access to the care and the social support they need. The CIE will provide real-time online information about the capacity of local agencies and non-profit groups to support people’s needs for social services like food and housing.

The multi-stakeholder, accountability-focused design of whole-person health care organizations enables them to meet people’s social and medical needs in a holistic way during COVID-19, while simultaneously improving the health and resilience of the larger regional and state health care ecosystem. As communities of color are devastated by COVID-19, these health care hubs models could offer a model for the future of equitable, trust-based community health and health care. 

(Originally published June 18, 2020 on The Hill)

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