of community care
HeaLTH sYSTEM TRANSFORMATION TO VALUE-BASED CARE DRIVES ENGAGEMENT INNOVATION
Community Care is that innovative space where Health Systems can effectively engage patient, payer and underserved populations for lifestyle behavioral change to slow, stop and reverse the progression of their chronic diseases in a low cost setting.
A Collaborative links Health Systems with community-based professionals that are educated and trained to be the Community Care Teams that deliver evidence-based chronic disease prevention and intervention programs at designated safe, accessible places. The Network Builders Team (NBT) is a design-build services organization that develops for Health Systems a Community Care Collaborative to expand accessible community-based points of care that are structured, replicable, scalable, cost transparent, private labeled and operationally audited for quality assurance. NBT provides the following four primary services to Health Systems: Collaborative Consulting, Professional Education, Community Development, and Quality Assurance.
We believe that real lasting lifestyle change is brought about by in-person engagement with people. Yes, we use technology to support our efforts, but relationships with real people lead to the level of engagement needed for behavioral change. Our Community Care Teams are made up of passionate, well-educated, and highly trained professionals who are up to the task of leading people to positive lifestyle change.
A Collaborative connects community-based professionals, places and prevention/intervention programs under the identity of Health System. The professionals are trained and credentialed to be the Community Care Teams for that can receive chronic disease patient referrals from the Clinical Care Teams.
The Community Care Teams extends Health System value-based care, population health management, and patient-centered medical home services into the community by delivering accessible chronic disease programs. Community Care in effect becomes a significant part of the chronic disease patient’s care plan and expands the Clinical Care Teams’ patient-centered care engagement capability by referring to trusted Community Care Teams.
As value-based payment models replace volume-based payment models, the focus is on top line payer revenue from value-based contracts that are associated with improving payer population outcomes and reducing the cost of care delivery. Payers can no longer cover the increasing cost of care particularly for chronic disease population groups.
Delivering preventive and intervention care in lower cost settings is the key to value-based care success. Integrating a Community Care Collaborative reduces the system’s risk by helping to manage delivery costs while meeting care quality measures and targets for payer populations.
A Collaborative approach is the most effective strategy to impact community awareness and loyalty while managing costs for those chronic disease patients that are rising-risk or at high-risk. Community Care can increase chronic disease patient engagement by 25 times or more in a year, an intensity that is absolutely necessary for improving lifestyle and behaviors.
Community Care Teams throughout the Health Systems’ service area can represent a new connection that redefines the relationship with the community at large by enhancing the patient experience, patient access, patient engagement and communication.
Community Care Teams
Community care teams are made up of professionals that have recieved specialized training in delivering programs designed to slow, stop, and reverse the progression of various disease conditions. NBT recruits, trains, and approves the professionals required to assemble community care teams around the country.
community care collaboratives
The transition of risk from payers to providers requires redesign, rethinking and retooling to achieve the level of transformation that will deliver on the promise of better outcomes. Disciplined approaches to rapidly testing new ideas that promote better patient care and outcomes must be tested in a real world context where the results are believable producing practice-based evidence that can be replicated as evidence-based practices.
NBT can demonstrate how a Community Care Collaborative can expand a Health System’s capability to engage patients in their service areas.
- Collaborative Consulting
- Professional Education
- Framework Development
- Quality Assurance
Healthcare innovation is not about iPhone apps. It's about disciplined approaches to rapidly testing new ideas to promote better patient care. We're moving into an era where 'getting away' with as little testing as possible is an essential feature of successful innovation--so long as that testing is done in a real context where the results are believable.
David A. Asch, M.D.
According to Dietz, et al. (2015), "A new framework is required that extends and integrates existing chronic care and population health models and articulates the distinct and shared roles of care delivery and community sys- tems to improve population health" (p. 1456).
Dietz, W. H., Solomon, L. S., Pronk, N., Ziegenhorn, S. K., Standish, M., Longjohn, M. M., ... & Bradley, D. W. (2015). An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases.Health Affairs, 34(9), 1456-1463.