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 mapping in your community.
- Identify your target population. Use data from a variety of sources to learn as much as possible about the needs of the population you want to serve.
- Create a list of services and supports that your target population will need for stabilization. Services may include, for example, access to behavioral health treatment, stable housing, transportation, addiction services, and pain management. Your list should include formal and informal services and community supports that are currently available, as well as those that need to be created in order to improve health outcomes for community members with complex needs.
- Match your list against services and programs currently available in the community. Organizations usually have staff who accept referrals for new clients. These people are good sources of information in terms of assessing service capacity, waiting lists, and eligibility requirements. Verify service availability as well as language and transportation accessibility. Ask whether individuals can get the help they need in a reasonable amount of time at low or no cost. For example, can people without insurance access pain management services without long waits for a scheduled appointment? What kinds of support are available for people who need housing assistance?
- Locate formal and informal assets and engage community partners willing to collaborate with you in developing new services and creating an ecosystem of care in your community.
- There are various ways to collect information to complete your asset map. You can do an internet search, interview professional colleagues and patients, and/or do a community survey. Local government websites and 211/311 systems often have current resource directories.
- Engage experienced case managers from different local or regional health and social services systems to identify the best resources for your specific population.
- Solicit both the provider and consumer voices in this process. Ask patients directly about what the most important services are to them.
- For the Uninsured in Memphis, a Stronger Safety Net – This commentary describes the efforts of Regional One Health to improve the health and wellness of Memphis’ most vulnerable residents. The Camden Coalition’s National Center for Complex Health and Social Needs worked with Regional One Health to design their ONEHealth care model to serve uninsured patients with complex needs.
- Competing Health Care Systems and Complex Patients: An Inter-professional Collaboration to Improve Outcomes and Reduce Health Care Costs – This journal article describes a collaboration between competing health systems to address the needs of a shared population of patients with complex health and social needs, the challenges involved, and how to overcome them. The paper also shares findings from the collaboration’s clinical impact and describes their collaborative model.
- Taking Care of Charlie Helped One California Town Nearly Halve Hospital Use – This piece, written by the Camden Coalition’s National Center for Complex Health and Social Needs’ Senior Advisor Lauran Hardin, describes how the cross-sector collaboration efforts of Project Restoration improved care for individuals with complex health and social needs in Clearlake, California.
- Cross-Sector Collaboration for Vulnerable Populations Reduces Utilization and Strengthens Community Partnerships – This research examines how Project Restoration addressed the needs of residents who often come in contact with the police, emergency, criminal justice, and health care systems in Clearlake, California. This collaboration resulted in reductions in hospital utilization, community response system usage, and cost.
This Better Care Play is part of a series developed in partnership with the Camden Coalition of Healthcare Providers to share practical lessons in serving complex populations.
- Related Blog Post: Using Asset Maps to Match Community Supports for Patients with Complex Care Needs: An Interview with the Camden Coalition’s Lauran Hardin – This interview with Lauran Hardin, Senior Advisor of Partnerships and Technical Assistance for the Camden Coalition of Healthcare Providers, explores the use of asset mapping to build stronger ecosystems of care and improve care delivery for individuals with complex health and social needs.
- Better Care Play: Enhance Patient Engagement Strategies through COACH – This play outlines how to use the COACH model and offers tips to providers who wish to enhance patient engagement.
- Better Care Play: Building Shared Outcomes with Community-Based Organizations - This play outlines steps to help health systems and community-based organizations build relationships that draw on each other’s strengths, put patients first, and support ecosystem development in local communities.
- Better Care Play: Initiating Health Care Data Sharing with a Social Service Organization - This play is designed to help health systems provide access to health-related data to social service organizations in their community.