Complex Care Redesign

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Care Neighborhood

Care Neighborhood is our intensive case management program that helps high-risk, high needs patients connect to local community resources and prevent unnecessary hospitalizations by focusing on addressing the social determinants of health.

How do we do it?

CHCN partners with the MediCal managed plans in the county. These partners currently administer the Health Homes and Whole Person Care programs that fund Care Neighborhood.  Care Neighborhood will soon be pivoting to a new funding stream, CalAIM, in 2022. Our patients that have complex medical and social issues are identified by the state and their names are sent to CHCN.  CHCN then adds the patient’s eligibility to the electronic health record (EHR) OCHIN Epic, where Community Health Workers (CHWs) in our 8 federally qualified healthcare clinics are able to do outreaches to patients.

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CHWs get to know their patients one on one and assess for their medical, behavioral and social needs. Afterwards they create a Care Plan with their patient.  CHWs and patients work together on the goals that the patient has identified as a priority to them first.  All patient goals align with various social determinants of health, such as housing, transportation and medical goals. CHWs meet their patients in the clinic, hospital, home or in the community depending on the patient’s needs. The ultimate goal is to support patients with obtaining the resources needed in order to be able to focus on their health goals.

CHCN’s CN Central staff includes a medical doctor, social workers, a nurse, lead CHW and a program coordinator to provide trainings, technical support and clinical support in the field.

CHCN’s data team supports the program with billing and tracking data through various data systems including Tableau and Structured Query Language (SQL).


Delivering Results

CHCN’s Care Neighborhood approach has demonstrated positive returns on investments including: decreased hospital re-admission rates, improved use of integrated behavioral health, decreased ER use and increased primary care visits. With ongoing support from our health plan partners we have 30 Community Health Workers in our 8 community health center organizations. Additionally, we have more than 750 patients enrolled in the program at any given time in year of 2021. Our program, Care Neighborhood, successfully continues to demonstrate total cost of care savings per member per month.


Care Neighborhood Technology

Care Neighborhood has partnered with OCHIN Epic to create a specialized case management platform integrated in the electronic health record. On the case management platform, Community Health Workers can review who they are working with, who is eligible for enrollment, and which of their enrolled patients are hospitalized. The case management platform also allows CHWs to view patient’s records, document encounter notes, care plan goals, and assessment results. All of the work done by CHWs within the case management platform is also visible to other clinic staff which provides opportunities for interdepartmental collaboration in patient care.

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Lastly, Care Neighborhood uses Tableau, a data visualization program, to present Care Neighborhood progress and impact. Tableau pulls data from Epic and demonstrates the growth of Care Neighborhood over time, and progress with the Care Neighborhood eligible population on an individual CHW level and on the larger programmatic level. CHWs can also use Tableau to monitor their own outreach and enrollment metrics, allowing for more effective caseload management.


Care Transition when patients are hospitalized

A core function of the Care Neighborhood program is to prevent hospitalizations by addressing the social determinants of health. Supporting patients during and immediately following a recent hospitalization is a key part of this process. Using internal data analytics tools, the Care Neighborhood clinical team tracks patients in the program who have been admitted to a local hospital. Using this information we are able to proactively coordinate with hospitals to ensure effective discharge planning for our patients. Community Health Workers help their patients connect with the appropriate resources when they leave the hospital. The Care Neighborhood nurse works closely with the CHW post-hospitalization to ensure smooth follow-up and get patients back into Primary Care. At the health care center, with support from Care Neighborhood staff, the Community Health Worker, Social Worker and Nurse review the patient’s hospital stay and consider ways to support their patient in preventing future hospitalizations.

Community health worker training 

Community Health Workers are hired directly by their health centers and are ideally from the community that they serve.  There is no requirement for CHWs to have done case management in the past.  Once hired, our experienced Lead Community Health Worker begins a week long training that covers Care Neighborhood processes and workflows, how to conduct assessments and to create Care Plans, community and government resources, and person-centered skills.  CHWs attend trainings covering Motivational Interviewing, Harm Reduction, Trauma-Informed Care, and Cultural Humility.  CHWs also have the opportunity to participate in CHCN’s Care Management Learning Community (CMLC).

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Training is not complete with didactics, however. CN’s training team provides multi-disciplinary elbow support while CHWs are learning to apply their new skills in the field. The Lead Community Health Worker provides one-on-one coaching to newly-trained CHWs as they begin to conduct outreaches, complete assessments, and build Care Plans. CN Social Workers accompany CHWs on their initial home visits, attend regular case conferences, and provide insight and support on complex cases. The CN Nurse accompanies CHWs as they begin to visit medically-complex patients in hospitals, skilled nursing facilities, and the patients’ homes.
Our CN community meets twice monthly for continued training, education and support at a meeting dubbed The Buzz. Our community partners are often invited to present their services at this meeting in order to help facilitate referrals. The Buzz also serves as an opportunity for ongoing medical and mental health education provided by CN clinical staff.