The adoption of value-based payment models may be slow going, but the shift is inevitable, including the move to downside risk. In our “Let’s Get Practical Series,” we have explored several areas in which risk-bearing organizations can build success, including how to design a good governance plan and how to support physicians as they take on downside risk.

You can add “growing strong community partnerships” to that list as well. Community partners are an essential resource as it becomes more critical to address the intersection between medicine and social benefits.

For healthcare organizations that decide to go deeper into risk, job number one is to shore up a fragmented system. You will need a day-to-day understanding of where your patients are, and ensure care is being delivered efficiently and effectively. To this point, community partners play a powerful role outside the four walls of the hospital. Their support can help make or break initiatives to drive better care coordination, improve outcomes, and keep costs down. The key is finding and nurturing the right community partnerships.

Re-envisioning your network

Community partners are a vital resource in connecting patients to clinical and non-clinical resources throughout the care continuum and community, as well as improving healthcare literacy. They can help organizations with downside risk arrangements gain a more accurate picture of the patient clinically and environmentally.

As organizations assume more risk, there is a lot of talk about expanding physician and provider networks to include community-based services that have specific functions outside of the insurance-payment cycle but still play an integral role in helping patients can stay in the community. Community organizations are adept at helping people understand their benefits and access healthcare in the right places, as well as providing health coaching and addressing socioeconomic needs from transportation and food access to social support. For instance, something as simple as helping an individual join a local book club and become more social can be a powerful motivator for engaging in better self-care and improving health and wellness.

Knitting tight partnerships

How do you identify community partners you can count on as you deliver on performance measures and seek the rewards of downside risk? Start by creating an inventory of community partner resources in every market. Contrary to what you might think, formal community partnerships do not necessarily drive success. Rather, strong lines of communication and a shared vision on how to address social determinants and other barriers to good health are the key ingredients for successful relationships with community partners.

It is critical to build a strong foundation with your community partners and establish deep relationships to better serve patients. Like any other relationship, your community partnerships require time, focus, and an ability to ask the right questions. When recommending patients to your community partner, you must be willing to provide as much information as possible and be an active ally who takes calls when clinical issues arise. Remember, when people go from one healthcare setting or service to another, they go into a black box. So you have to be willing to check on them and to support the community-based provider.

Keep an open dialog and have conversations with your community partners on at least a quarterly basis to ensure you are sending them the right people, handoffs are done correctly, and that you fully understand their capacity. When it comes to handoffs to another clinical setting of care or to home, there continues to be a lack of understanding about the true available resources. Therefore, it is important to maintain on-point communication with your community partner, so they can provide the best support possible for the patient after discharge.

At the same time, the relationship should be a two-way street in which your community partner is equally adept at recommendations and strong communication. For example, when the need arises, the local food bank you recommend should be equipped to identify a customer’s socioeconomic situation, social determinants of health, as well as what is happening clinically and recommend them to the right place within the healthcare system.

Measuring success

Most healthcare organizations aren’t able to perform longitudinal studies but there are less complex ways to evaluate the effectiveness of a community partnership. A couple of practical measures to look at are whether or not the community resource continues to give support and if patients are improving. There should also be a drop in inappropriate use of certain care settings such as the emergency room and fewer hospital readmissions. Overall, if your community partnerships are working, patients will have a better understanding of available clinical and community resources and how to access care.