Building the Foundation for Successful Community-based Care Collaboration

After an intense week at #ViVE2024 with ScaleHealth , I skipped the next conferences (#SXSW & #HIMSS) for a unique experience. I traveled through California's Salinas and San Joaquin valleys with the Camden Coalition . Our mission? To work with stakeholders on #CalAIM, the state's ambitious Medi-Cal transformation initiative.

My journey through rural California revealed a surprising truth: old-fashioned, in-person connections are crucial. While digital health, data sharing, and interoperability tools are important for scaling care, they can't replace the power of human connection.? Strengthening local collaboration is the first step to ensure these new services reach those who need them most.

The Secret Sauce of Collaboration

So, what are the key ingredients for successful community-based care collaboration?

• Authentic Healing Relationships: The foundation of CalAIM is trust. We build this by fostering secure, genuine, and continuous connections. Patients and clients need to feel seen, heard, and respected. Providers, in turn, must establish appropriate boundaries and follow through on commitments.
• Documented Community Workflows: Sometimes, all it takes is a phone call to a trusted colleague who has the exact resource a client needs. But other times, complex situations require collaboration beyond what any single organization can offer. Often, these connections and resources exist but reside in personal notes, weathered social service binders, or simply a key employee's memory. Before jumping to digital solutions, it's critical to map the local ecosystem and document these formal and informal community workflows.

Case Conferencing: As trust builds, connections form, and workflows are documented, a natural desire to collaborate emerges. This is where case conferencing comes in. It's a structured, planned event separate from routine coordination. Here, a team of internal and external providers (ideally interdisciplinary) comes together to review the case of a de-identified client with complex needs. This collaborative approach focuses on:

• Capturing the client's story
• Including all providers who intersect with the client
• Finding solutions together
• Developing a shared plan of care

The Camden Coalition is actively working with CalAIM stakeholders to implement case conferencing strategies in 2024.

The Role of Digital Health

Digital health isn't left out of the conversation. Companies like Pear Suite , Trust , Rosarium Health , Pair Team , ClinNEXUS ,and Zócalo Health are actively involved in these communities. They're listening, learning alongside providers, and contributing to the conversation. Their role is to support and strengthen, not replace, the human connections at the core of successful community care.

The Journey Continues

This is an ongoing process, and collaboration is key. We're all in this together, working towards a future where community-based care truly transforms lives.