Resources

Developing authentic healing relationships is critical to applying interventions that fully support patients in achieving their goals. The Camden Coalition’s patient engagement framework, COACH, focuses on building these relationships and empowering patients to take full control of their health. This practical play outlines how to use the COACH model and offers tips to providers who wish to enhance patient engagement. DOWNLOAD AS A PDF »
Mapping community resources is a good starting point for developing the system of care needed to interrupt the cycle of hospitalization and emergency department use and create a pathway to health for patients with complex needs. Effective complex care models rest on a foundation of services and supports that go beyond the traditional reach of the health care system. Community asset mapping offers a practical framework for locating and cataloguing a full array of services and for identifying critical care gaps and potential partners. The goal of this play is to help you get started with asset...
In an environment where social determinants are playing more of a role in conversations about improving health outcomes, it is critical for the health care and social sectors (which often take the form of local community-based organizations, referred to as CBOs) to build mutually beneficial partnerships. This play outlines steps to help health systems and CBOs build relationships that draw on each other’s strengths, put patients first, and support ecosystem development in local communities. DOWNLOAD AS A PDF »
Access to a health care data-sharing platform can help social service providers better understand and address issues that lie at the intersection of their clients’ social and medical wellbeing. It can: (1) provide insight into relevant details of the medical situation that their client is facing; (2) help the social service organization identify clinicians who may be valuable partners in the individual’s care; and (3) enable them to access documentation that can help them better advocate for the client. The goal of this play is to help health systems provide access to health-related data to...
Transitional care programs — where a multidisciplinary team comprehensively assesses a patient’s medical and psychosocial needs, addresses modifiable barriers, and links them to primary care — can help address critical gaps in care for people with complex needs moving between locations of care, such as from hospital to home. These programs vary widely, both in terms of what services they provide, and whether services are delivered before hospital discharge, after discharge, or as part of a “bridging” intervention with both pre- and post-discharge components. A comparative effectiveness trial...
This play was produced by the Institute for Healthcare Improvement (IHI) and authored by Rush University Medical Center's Center for Health and Social Care Integration. Integrating social workers into primary care teams can help improve patients’ health by proactively addressing their social determinants of health and mental health needs. This integration also reduces the burden on providers and helps organizations to reach their institutional quality goals. By using patient and family engagement techniques, leveraging community-based supports, and coordinating care, social workers can improve...
This play was produced by the Institute for Healthcare Improvement (IHI) and authored by Corey Waller, MD. Substance use disorder, commonly called addiction, is a treatable chronic disease that is a significant contributor to health care utilization and poor health outcomes in the United States. Even though it is estimated that up to 60 percent of patients in the US Level 1 Trauma Centers meet the criteria for a substance use disorder, few hospital emergency departments have a service line for these patients. This Play can help you treat substance use disorder in the emergency department as...
Substance abuse disorder, commonly called addiction, is a treatable chronic disease that is a significant contributor to health care utilization and poor health outcomes. It’s estimated that up to 60 percent of patients in U.S. Level 1 Trauma Centers meet the criteria for a substance use disorder. Inpatient treatment for substance use disorder can improve recovery time and decrease length of stay, escalations of behavior, and 30-day readmissions. But few hospitals have a service line for these patients that goes from hospital admission, including through the emergency department, to discharge...
Human-centered design offers a methodology and mindset that can help you develop a complex care program that addresses the realities of the people you serve. People with complex needs have complex lives, attitudes, and behaviors that are often based on life outside the medical system. The human-centered design approach aims to make systems usable and useful by involving the human perspective in all steps of the problem-solving process. For example, Stanford Coordinated Care used design thinking to identify patients’ need to have facts translated into actionable advice; one care coordinator...
This play was developed by the Institute for Healthcare Improvement (IHI) as a tool for effectively presenting a team’s work to a variety of audiences and stakeholders. All programs have to continuously prove themselves as they prototype, implement, expand, and go to scale. Complex care programs often have a lot of stakeholders: senior leaders, payers or other funders, primary care providers, and the field of complex care, among others. Storyboards that include run charts are useful in keeping stakeholders engaged in the program’s results and demonstrating the program’s commitment to data and...
Patients with complex needs often see multiple providers for different health conditions, including providers in emergency departments, multiple health systems, and in mental health services. Coordinated care plans can help keep all providers informed about the patient’s needs and preferences, helping to coordinate care and decrease waste. While the concept is simple, the implementation of care plans can be challenging. Useful care plans must be concise, goal-oriented, and up-to-date, and there may be no pre-existing way to share care plans within and across health systems. The goal of this...
This play was developed by the Institute for Healthcare Improvement (IHI) based on their work in the Better Health and Lower Costs for People with Complex Needs collaborative, which ran from 2014-2017. Evidence has shown that health coaching can help patients improve their health. Health coaching helps patients build the knowledge, skills, and confidence required to manage their chronic conditions. Health coaches empower patients to play a central role in clinical encounters and to engage in self-management activities at home, work, and school, where they spend most of their lives. Therefore...