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What's New | September 15, 2010

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Community Care Coordination Community Care Coordination
Identifying at-risk individuals and connecting them to appropriate care can improve health outcomes and reduce health disparities. Community care coordination aims to improve the quality, efficiency, and coordination of health care and social services for at-risk populations. Such programs often use community health workers or navigators to help coordinate services.

The featured Innovations describe three programs that used the Pathways© model of community care coordination to connect at-risk individuals to needed services, thereby improving health outcomes.

The featured QualityTools provide resources that can assist communities in their efforts to improve the quality and coordination of health care services.
Featured Innovations:

•  Care “Pathway” Connects Pregnant Substance Abusers to Medical and Other Services, Supporting  Birth of Babies with Viable Weights Who Are Free of Illicit Substances

•  Program Uses "Pathways" to Confirm Those At-Risk Connect to Community Based Health and Social Services, Leading to Improved Outcomes

•  Updated Community Health Navigators Use Pathways Model to Enhance Access to Health and Social Services for Low-Income, At-Risk Residents

Featured QualityTools:

• Connecting Those at Risk to Care: A Guide to Building a Community "HUB" to Promote a System of Collaboration, Accountability, and Improved Outcomes
Developed by Community Care Coordination Learning Network

• Pathways: Building a Community Outcome Production Model
Developed by Community Health Access Project

• Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives
Developed by Agency for Healthcare Research and Quality

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Also in This Issue:
Innovations >

• Community Partnership Uses Lay Health Advisers to Reduce Chronic Disease Risk Factors, Leading to Improvements in Lifestyle and Health in Low-Income African Americans

• Health Clinics and Community Organization Coordinate Outreach Workers to Educate and Support Farm Workers, Leading to Healthier Behaviors and Higher Satisfaction

• Hospital Provides Non-English-Speaking Patients With Recording of Discharge Instructions in Native Language, Leading to Improved Comprehension and High Satisfaction

• Multiagency Collaborative Helps Community-Dwelling Seniors Access Coordinated Support Services, Helping Them to Remain in Their Homes
with Story

• Quality Improvement Collaborative Helps Clinic Serving the Uninsured to Significantly Increase Colorectal Cancer Screening and Smoking Cessation Education

• Six-Month Weight Management Program for African-American Women Church Congregants Improves Behaviors, Blood Pressure, and Body Mass Index

• Updated Community Health Collaborative Reduces Inappropriate Emergency Department Use by Providing Access to Health Care, Social Support for Low-Income Clients

QualityTools >

• Asthma Return-on-Investment Calculator
Developed by Thomson Reuters

• Community Asthma Prevention Program (CAPP): Resources for Professionals
Developed by Children's Hospital of Philadelphia

• Electronic Health Record Adoption Process
Developed by HealthInsight

• Making Needles Hurt Less
Developed by Children's Healthcare of Atlanta

• Map My Community
Developed by Interagency Working Group on Youth Programs