Care Transitions: Building Partnerships to Support Health Related Social Needs
The HHS Administration for Community Living (ACL) is inviting hospitals, health systems, Accountable Care Organizations (ACOs) and community-based organizations (CBOs) to a special series of learning events and discussions around collaborative approaches to screening for health–related social needs (HRSN), connecting with community-based social services, and supporting hospital transitions pre- and post-discharge.
The monthly meeting series and peer discussion groups will run from January through August 2024. The goal is to leverage community partnerships and assets to address patients’ unmet health-related social needs. This learning opportunity uses the Extension for Community Healthcare Outcomes (ECHO) Model®, an “all teach, all learn” approach to peer-based learning. Participating teams will learn from leaders with successful approaches to HRSN screening, referral, and care transition programs and be equipped with actionable strategies to implement in their own organizations.
To participate in the virtual ECHO series, CBOs should have a relationship (formal or informal) with a local hospital. Hospitals should have an interest in or already have a formal or informal relationship with a local CBO that serves older adults or people with disabilities. Hospitals seeking a CBO partner will receive support in identifying one. ACO partners are also invited to participate as the series will address team-based approaches to care management and community health integration post-discharge. Recommended organizational attendees may include case managers, discharge planning staff, quality measurement professionals, and senior leadership overseeing population health.
If your organization is interested in participating, please complete this brief survey prior to January 12, 2024, to indicate interest: ACL Care Transitions ECHO (smartsheet.com). If you have any questions or would like support identifying a CBO partner, please contact caretransitions@lewin.com. We look forward to hearing from you!
Series Overview |
Session 1: Impact of Social Needs on Transitions from Hospital to Home This session provides framing for the entire ECHO Series and answers the question: Why now? Participants will come away with a clear understanding of the ECHO Model framework, expectations, and topics to be discussed across the entire series. Specific focus is given to current policies and requirements for addressing social needs including:
What does this mean for hospitals? CBOs? What is the connection to care transitions? Learn from your peers through a hospital/CBO case study outlining their successes and challenges in navigating these new requirements and expectations. Participants will receive a fictional workflow outlining best practices in addressing social needs that can be customized to partners’ unique needs. This workflow will be used during Peer Working Sessions to foster learning and sharing from leaders and subject matter experts as well as those who are just getting their feet wet. The goal is to realize incremental progress toward partnership development and strategic alignments to address HRSNs during transitions.
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Session 2: Screening for Health-Related Social Needs There is much talk about the new HRSN screening requirements. How do you navigate all these requirements and what are some of the real roadblocks in achieving success? How do you document and identify trends in social needs? When and how do you connect with your CBO partners? Specific focus is given to the mechanics and roles in screening for HRSN including:
Learn from your peers through a case study on how to make successful referrals, ensure follow up, and close the loop in addressing HRSN for individuals transitioning from hospital to community. Participants will receive tools outlining the entire looped process from screening, documentation, referral, and follow-up that can be customized to each partner’s models and processes and will be shared by leadership and subject matter experts during the Peer Working Sessions.
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Session 3: Communication Pathways You’ve identified HRSN needs. Now what? Communication is the connective tissue that bridges each step of the process that supports the development of a patient’s person-centered discharge plan back to the community. There are many stakeholders involved in the process. Learn how the TEAMS STEPPs evidence-based framework and tools can assist you in optimizing communications across care transition activities. Specific topics include:
Via a case study discussion, learn how a hospital and CBO network implemented communication workflows to expedite referrals and communication necessary to ensure service delivery and documentation post-discharge. Participants will receive a worksheet that outlines key communication handoffs and the role that each partner could play. Participants will customize the communication processes to their own models and systems and discuss in the Peer Working Session among advanced and new partners. Peer Working Session Resource #3_2024.03.18_FINAL |
Session 4: Methods of CBO Engagement for People in Transition Navigating the discharge and transition process and ensuring people receive the supports needed when back in the community is not easy. With heightened focus on the impact of unmet health related social needs, building partnerships with CBOs that bring decades of experience in SDOH service delivery and coordination is both helpful and smart. Learn how coding of interventions is an important strategy not only for referrals but also for documentation and billing purposes. Specific topics include:
Learn how tools and coding can be used to positively drive transitions. Participants will receive a worksheet outlining options for sustainability via revenue streams with suggested follow up steps to take based upon each partnerships’ unique models and needs. |
Session 5: Short and Long-Term Supports – The Role of the CBOs and Post-Discharge Providers Realizing successful transitions that avoid unnecessary readmissions and lengths of stay are dependent upon strong partnerships, clear communication, and follow up. Ensuring referrals are made, services are delivered, and follow up occurs post-discharge is critical. How can CBOs be helpful to hospitals, ACOs, and other healthcare partners and vice versa as transitions are underway? What can CBOs do to make sure healthcare partners are aware of service and support options in the community? How can hospitals and CBOs become problem solvers together vs operating in isolation? Learn about effective strategies for:
Participants will receive a fictitious example, to be customized by partners, providing options for how partners may want to respond to a hospital referral in a successful way with specific suggestions and important timelines to implement post-discharge services as quickly and smoothly as possible. |
Session 6: Concurrent Billing Payment pathways for HRSN screening and responding to unmet needs is top of mind for healthcare providers and CBOs. What are the vehicles that drive billing for transition activities? Where do CBOs stand to benefit with being able to receive payment for their work? What is the connection between billing and quality? What is the Part B Medicare provider connection? Specific topics in this ECHO event include:
Participants will receive a worksheet providing an overview of how hospitals and CBOs can consider working together to address unnecessary readmissions due to unmet social needs or chronic care readmissions using communication loop models tested via short PDSA cycles. |
Session 7: Closing the Loop with Medicare Part B Providers To come full circle and “close the loop” for a transition, connections need to be made with Medicare Part B providers. CBOs can be the critical connective tissue between Part B providers and their patients. How do CBOs support Part B providers? How do CBOs serve as extensions of Part B providers to ensure post-discharge follow-up and service delivery? How can Part B providers and CBOs work hand in hand to ensure smooth transitions? Specific topics include:
Participants will receive a worksheet with a fictional fully developed loop and workflow based on the learnings from the series to customize to their own models and needs. This includes a financial model for consideration. |
Session 8: Wrap Up and Celebrations The final ECHO series event, this session will first provide an overview of any new national policies and relevance to this work and ongoing opportunities to further develop community partnerships. Come celebrate the efforts of all partners and contributors to this 8-month series. Topics will cover:
Via case study, the partnership that advanced the most will be featured and benefit from group discussion. |
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