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Stronger Together: Community-based care coordination

Updated: Jun 14, 2021

Olympic Community of Health (OCH) brought together partners from across the Olympic region to learn about creative approaches to community-based care coordination. With care coordination, costs are reduced across systems and the savings can be reinvested in preventative programs or other services. This convening was an opportunity to discuss different ways to effectively connect, communicate, and coordinate among clinical and community-based agencies, ultimately fostering a region of healthy people and thriving communities.

What is community-based care coordination?

Community-based care coordination truly embodies OCH’s purpose “tackling health issues that no single sector or Tribe can tackle alone.” This approach to care coordination brings together various organizations, Tribes, and sectors to collaboratively care for the unique needs of a specific community. Care coordination communicates the patient’s needs and preferences to ensure clients receive “the right care at the right place and the right time”.

It is defined as: “Deliberately organizing patient care activities and sharing information among all the participants involved with a patient’s care to achieve safer and more effective care” (Agency for Healthcare Research and Quality).

Clallam Care Connection: Community-based care coordination in action

A local example of care coordination in action is Clallam Care Connection (3C). 3C provides coordinated care to improve the health status of individuals with complex, chronic conditions to deliver a seamless experience of care that is person-centered, cost-effective, addresses social determinants of health, and results in improved health and wellness.

3C focuses on providing care coordination for clients with:

  • complex chronic disease including serious mental health and substance use disorders

  • a history of disjointed or discontinuous healthcare

  • multiple preventable 911 or department visits

The 3C team includes North Olympic Health Network, Port Angeles Fire Department, the REdisCOVERY Program, and Peninsula Behavioral Health, with support from Olympic Community of Health.

During the initial pilot period, 3C has seen a 90% decline in 911 calls among eight community members who graduated from the 3C program. 3C has seen a cost savings of over $100,000 by preventing 67 emergency calls and medic unit rollout.

Care coordination across the region

  • Jefferson Healthcare specifically does care coordination for Jefferson Healthcare patients. Dunia Faulx is the main contact | | 360-385-2200 ext 4955

  • Olympic Area Agency on Aging facilitates care coordination for dual eligible community members (enrolled in both Medicaid and Medicare) via Health Homes. Jody Moss is the main contact | | 360-379-5064.

  • Kitsap Public Health District is working in Kitsap for Birth to Three Centralized Intake. Working with Karla Cain from Answers Counseling and Olympic Educational Service District (OESD). Nancy Acosta is their main contact | 360-731-6144.

  • The YMCA of Pierce and Kitsap Counties does care coordination for evidence-based programs for community members with health care partners both virtually and through place-based strategies. They also support state-wide virtual programs. Susan Buell is their main contact | | 253-460-8912.

  • Unite Us is interested in engaging further with folks to learn more about local projects and efforts to see if Unite Us might be a good partner. Christine Hoffmann is their main contact | | 360-742-7904

  • Many OCH implementation partners are tackling care coordination in their community-clinical linkage project proposals and enhanced transformation project proposals.

Next steps

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