Description: Delivering effective complex care requires an empathetic understanding that the human experience is complicated and that poor health and inadequate living conditions have multiple causes, including an interplay of physical and behavioral health, structural and social conditions, racism, stigma, and bias.

Context: These competencies constitute an orientation that complex care team members apply to interactions with individuals, teams, and systems. Using that orientation to inquire about, listen for, and adapt to an individual’s context is especially important in complex care because the intersection of health and social needs, exposure to trauma, and stigma evolve throughout the lifespan. Complex care team members understand these complexities and support individuals in reaching their goals within their own context. Additionally, many challenges and inequities faced by individuals are ingrained in governmental, cultural, and social systems and thus environment and context are not always immediately modifiable. Complex care team members aim to balance seeking to change an individual’s environment and supporting them within it.

Competency 1. Obtain and apply foundational knowledge in:

Physical and behavioral health as relevant to the discipline and context

• Describe basic concepts relevant to human growth and development, disability, disease states, and chronic disease management.
• Understand basic concepts about substances, substance use disorders, and substance-related health conditions.
• Demonstrate basic knowledge of the biological, social, affective, and cognitive bases of behavior.

Resources:

• Medications for addiction treatment: Commonly used acronyms and abbreviations (pg 10) – A glossary from the National Center for Complex Health and Social Needs (National Center) with commonly used acronyms and abbreviations in addiction care
• Substance use disorder 101 – A powerpoint presentation from the Camden Coalition of Healthcare Providers (Camden Coalition) on the basics of substance use disorders
• Mental health 101 – A powerpoint presentation from the Camden Coalition on the fundamentals of mental health
• Attachment – A lesson plan and set of resources from the National Center on attachment theory
• Addiction – A lesson plan and set of resources from the National Center on addiction
• Medications for addiction treatment (MAT) – A lesson plan and set of resources from the National Center on medications for addiction treatment (MAT) (also known as medication-assisted treatment)
• Project TRANSFORM-Teaching Recovery-informed Addiction Care and Negating Stigma FOR Medical Professionals – A lesson plan with voiceover powerpoints and videos of people with lived experience from Prisma Health-Upstate, University of South Carolina School of Medicine-Greenville and Clemson University School of Nursing provides training for professionals on healthcare teams who, in the course of their roles, may serve individuals and families affected by substance use disorder.

Social drivers of health

• Understand the health and healthcare utilization impact of social deprivation and unmet needs.
• Analyze the macro (e.g., housing policy) and mezzo (e.g., social class, gender, race, ethnicity, place of birth, disability, physical environments) determinants of individuals’ and populations’ health.

Resources:

• A place at the table – Video series from the New York Times on food insecurity among various populations
• Social determinants of health (SDOH) training plan – A self-guided training plan from the Centers for Disease Control and Prevention (CDC) that describes fundamental aspects of SDOH, explains social contexts and effects of SDOH on specific populations, and applies SDOH knowledge to design targeted interventions for improving public health
• What makes us get sick? Look upstream – TEDx Talk by Dr. Rishi Manchanda on another way of examining social determinants of health
• When your symptoms don’t tell the whole story – Podcast from Marketplace on the importance of non-medical needs

Interplay and compounding effects of multiple health and social needs

• Consider the interplay and compounding effects of multiple health and social needs (comorbidity).

Resources:

• Co-occurring disorders and other health conditions – A lesson plan from the Substance Abuse and Mental Health Services Administration (SAMHSA) about co-occurring disorders and other health conditions that can occur in people who are in medication-assisted treatment (MAT) for substance use disorders

Frameworks used in the care of people with complex needs such as recovery model, strengths-based practice, resilience, and person-in-environment

• Identify and apply frameworks used to understand and provide care for complex needs.

Resources:

• Simple guide to ecomaps – Visual tool and set of instructions from Strong Bonds and Jesuit Social Services on the process of developing case plans
• Ecomap – Worksheet from the National Center that helps you to more specifically understand and implement ecomapping
• Care Act guidance on strengths-based approaches – A guide from Social Care Institute for Excellence on the process and key elements to consider in relation to using a strengths-based approach
• The power of vulnerability – TEDx Talk on the significance of emotional empathy. What makes a good life? Lessons from the longest study on happiness A TEDx Talk on human connection in a healthcare settings

Trauma-informed care, including the impact of adverse childhood experiences, historical trauma, and structural oppression (e.g., racism, sexism, etc.)

• Define the core concepts of adverse childhood experiences, trauma, toxic stress response, trauma-informed and trauma-specific care, and retraumatization.
• Promote environments of healing and recovery in the context of historical and ongoing trauma to avoid further harm.

Resources:

• SAMHSA’s concept of trauma and guidance for a trauma-informed approach – A guide from SAMHSA that helps you to develop a working concept of trauma and trauma-informed approach
• Trauma therapy & evidence based practice: The basics – Powerpoint presentation from Southern Illinois University School of Medicine (SIU SOM) explores the history of trauma therapy and evidence-based practices
• Trauma-informed care – A presentation from SIU SOM that teaches about trauma’s complex impact, creative and compassionate responses, and caring for self
• Resilience – This film from KPJR Films helps with understanding adverse childhood experiences (ACEs)
• How childhood trauma affects health across a lifetime – A TEDx Talk on understanding the long-lasting impact of childhood trauma
• The Institute on Trauma and Trauma-Informed Care (ITTIC) – Online modules from University at Buffalo: Buffalo Center for Social Research help shift thinking from “What is wrong with this person?” to “What has happened to this person?”
• Medications for addiction treatment: Addiction, trauma and resilience (pg 21-23)– A toolkit from the National Center on providing trauma-informed care in the context of substance use
• Healing Neen: Trauma and recovery A documentary from The Hollow Films that examines the story of Tonier “Neen” Cain’s emergence from drug addiction, multiple incarcerations and two decades of homelessness to become a tireless advocate and educator
• Neurobiology of trauma A lesson plan and set of resources from the National Center on understanding trauma from a biological perspective
• Adverse childhood experiences (ACEs) A lesson plan and set of resources from the National Center on the impact and implications of adverse childhood experiences
• Trauma-informed care: Implementation resource center A website from Center for Health Care Strategies includes resources from trauma-informed care leaders across the country that are designed to help improve patient outcomes, increase patient and staff resilience, and reduce avoidable healthcare service use and costs

Philosophy and practice of harm reduction

• Define and apply the core principles and practices of harm reduction.

Resources:

• Harm reduction training – A three-part powerpoint presentation from Hill Country Community Clinic helps you train others on harm reduction philosophy and practices. The first two parts are 1.5 hours minimum and the third part is 1 hour minimum. The training is optimally provided in-person
• Insite – not just injecting, but connecting – This video from Drugreporter provides an example of harm reduction work in action
• Harm reduction education on demand – A self-paced course from Harm Reduction Coalition provides a deeper perspective into harm reduction principles and practices

Models and techniques of behavior change

• Identify and apply methods of engagement and care delivery that promote behavior change to achieve the individual’s goals.
• Examine the challenges of and opportunities for human behavior change.

Resources:

• Tour of motivational interviewing – A course from the University of California, Los Angeles on the essential skills used to strengthen an individual’s motivation for behavior change
• Introduction to motivational interviewing – A video from Bill Matulich on the basic concepts of Motivational Interviewing (MI). After a brief definition, topics include: the Spirit of MI, The four basic OARS skills, and the “processes” of MI
• The ineffective physician: Non-motivational approach – A video from MerloLab provides an example of how NOT to approach motivational interviewing
• The effective physician: Motivational interviewing demonstration – This video from MerloLab provides an example of motivational interviewing.
• Assessing readiness to change: Transtheoretical model – A guide and worksheet from the Preventive Cardiovascular Nurses Association to introduce the stages of behavior change.
• Supporting healthy communities and behavior change through planning with theory – A powerpoint presentation from Rhode Island Coalition Against Domestic Violence communicates three leading behavioral change theories
• Motivational interview graded standardized patient encounter via telemedicine – This simulated encounter and lesson plan notes from Augusta University/University of Georgia Medical Partnership teaches communication and motivational interviewing best practices in a telemedicine format

Competency 2. Evaluate, respect, and incorporate the diversity of values, strengths, cultures, and personal preferences of individuals, families, and colleagues.

• Assume a stance of cultural humility to understand the needs of individuals.
• Apply cultural intelligence skills and strengths-based practice to support the needs of individuals with diverse backgrounds.

Resources:

• Cross-cultural issues in integrated care – A powerpoint presentation from SAMHSA on communicating about health disparities, the importance of cross-cultural education, and practical methods for improving cultural competence
• Improving cultural competency for behavioral health professions – Training modules from the US Department of Health and Human Services (HHS) that help behavioral health professionals increase their cultural and linguistic competency
• Cultural competency/humility – General and specialty trainings from Colorado School of Public Health about cultural humility, cultural competency, and cultural diversity
• Cultural competence – A curricula enhancement module series from the National Center for Cultural Competence that helps faculty incorporate key cultural and linguistic competence content areas into existing curricula, offers resources for each content area, and provides instructional and self-discovery strategies.
• A practical guide to implementing the national CLAS standards: For racial, ethnic and linguistic minorities, people with disabilities and sexual and gender minorities – A practical guide from the Centers for Medicare & Medicaid Services on implementing the National CLAS Standards and improving health equity.
• LGBTQ health clinical training using the eQuality toolkit – An online primer training from the University of Louisville School of Medicine on addressing gaps in patient care for those who identify as a part of the LGBTQ community

Competency 3. Apply tenacity, ingenuity, and divergent thinking to actively work to eliminate complex and deeply ingrained individual- and community-level health disparities.

• Demonstrate the discipline, determination, and resilience necessary to achieve goals in the face of setbacks, obstacles, or challenging environments.
• Describe strategies to solve difficult problems in original, clever, and inventive ways.

Resources:

• Uncertainty as the norm – A video from the National Center on how leaders think about the future of complex care
• Adaptability and flexibility – A lesson plan and presentation from Health Workforce Initiative (HWI) on the importance of adaptability and flexibility.

Description: Complex care team members are deeply and ethically committed to improving the lives of individuals experiencing vulnerability, believe in transformative change at the individual and system levels, engage in continuous learning and self-improvement, and serve as examples of hope and ingenuity.

Context: The work of complex care can be both deeply challenging and rewarding. It requires significant self-reflection to identify and overcome ingrained biases. Routine personal and team check-ins can help sustain a commitment to working with individuals who have complex needs despite the systemic barriers and challenges individuals are facing.

Competency 1. Develop, implement, and evaluate innovative approaches to supporting individuals and families.

• Understand traditional approaches to supporting individuals and families, including their limitations and challenges.
• Pilot and test new and creative approaches to maximize the effectiveness of care and support for individuals.
• Solicit feedback from individuals receiving care and colleagues regarding effective methods of engagement, care planning, and care delivery.

Resources:

• BUDNER TOL – A tool from the University of Utah for assessing a learner’s tolerance for ambiguity
• Walking the talk: Consumer centricity via journey mapping and the lived experiences of your consumers – A powerpoint presentation from Commonwealth Care Alliance on journey-mapping
• Lifelong learning (presentation and lesson plan) – A lesson plan and presentation from Healthcare Workforce Initiative on the importance of innovative approaches and ongoing learning

Competency 2. Champion resilience and a strengths-based perspective for individuals, families, communities, teams, and systems.

• Support individuals in adapting to or challenging change and overcoming adversity.
• Identify and support individuals in identifying their own strengths, resourcefulness, and resilience in the face of adversity.
• Communicate specific examples of individuals’ strengths, resourcefulness, and resiliency to themselves, their families, and their other practitioners.
• Use techniques to build on individuals and families’ strengths.

Resources:

• Forming, storming, norming, and performing: Bruce Tuckman’s team stages model explained – A video from MindToolsVideos on Bruce Tuckman’s stages of teaming
• Strengths-based approach – An article with activities and examples from Positive Psychology about developing a strengths-based approach
• How childhood trauma affects health across a lifetime – A TEDx Talk that provides an example of resiliency

Competency 3. Identify and develop strategies of self-care to address moral injury and foster joy in work.

• Identify individual strategies to protect and nurture one’s own well-being.
• Identify team-based strategies to sustain and promote team member well-being.

Resources:

• Action collaborative on clinician well-being and resilience – A collection of resources from the National Academy of Medicine to improve clinician/practitioner well-being
• Developing a self-care plan worksheet – A worksheet from Bread for the City to plan for a self-care routine
• Battling burnout: Self-care and organizational tools to increase community health worker retention and satisfaction – A guide from Health Leads that helps managers prevent and address burnout
• Identifying emotional triggers – A video from the Camden Coalition on the identification and mitigation of emotional triggers
• Vicarious trauma A presentation from the National Center and Adventist Health on the fundamentals of vicarious trauma, examples of vicarious trauma, and protective factors against vicarious trauma

Competency 4. Employ the skills and perspective of self-reflection, cultural humility, anti-racism, and unconditional positive regard to mitigate personal and systemic biases and stigmas and to repair historical and personal harms.

• Cultivate a practice of active self-reflection.
• Exhibit a non-judgmental openness to and celebration of personal and cultural identities.
• Demonstrate unconditional acceptance of individuals by setting aside personal opinions and biases.
• Cultivate an understanding of structural racism and implicit bias and the strategies to dismantle racism.
• Implement strategies to develop in self and others the skills of cultural intelligence.

Resources:

• Unconditionally accepting myself so I can unconditionally accept others – A video from the Camden Coalition on the value of unconditional acceptance
• Managing your need to fix – A video from the Camden Coalition helps on how to resist problem-solving when inappropriate.
• Medications for addiction treatment: Stigma in clinic settings (pg 30) – A toolkit from the National Center on reducing stigma in your setting
• Self-reflection (presentation and lesson plan) – A lesson plan and presentation from HWI for teaching and facilitating self-reflection
• Non-judgemental listening – A tipsheet from Mental Health First Aid on non-judgemental listening
• Unconditional acceptance – Powerpoint presentation from Mental Health First Aid on Carl Rogers’ theories and practices of unconditional positive regard
• Structural racism and implicit bias – Lesson plan from the National Center for Cultural Competence about conscious and unconscious biases in healthcare and their impact on people who are disproportionately affected by disparities in health and healthcare
• Best intentions: Using the implicit associations test to promote reflection about personal bias – An exercise from MEdEdPORTAL helps students with some clinical experience cultivate awareness or bias and foster self-reflection through an exercise that challenges assumptions about personal bias
• Health equity rounds: An interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees – A longitudinal case conference curriculum called Health Equity Rounds (HER) from MedEdPORTAL on the impact of structural racism and implicit bias on care delivery.
• Words matter: An antibias workshop for health care professionals to reduce stigmatizing language – An interactive workshop from MedEdPORTAL with a framework for identifying and replacing stigmatizing language in clinical practice
• How assumptions and preferences can affect patient care: An introduction to implicit bias for first-year medical students- A 1-hour interactive multimedia lecture and active reflection from MedEdPORTAL on the impact of implicit bias on care delivery
• Implicit bias recognition and management in interpersonal encounters and the learning environment: A skills-based curriculum for medical students – Curriculum from MedEdPORTAL on recognizing and managing implicit bias
• Teaching intersectionality of sexual orientation, gender identity, and race/ethnicity in a health disparities course – Lecture and video series from MedEdPORTAL on the basic concept of intersectionality in the context of health disparities.

Competency 5. Understand and maintain appropriate professional boundaries and limitations within relationship-delivered care.

• Understand the essential elements of professional relationships and the dangers associated with boundary crossing.
• Identify and apply the boundaries of professional ability and scope of practice.

Resources:

• Got boundaries? Building safe space and navigating relationships in a Housing First program in Camden, NJ (video)
• Got boundaries (powerpoint) – A video and powerpoint presentation from the Camden Coalition on appropriate boundaries.

Description: Complex care team members value the autonomy and agency of individuals and families and recognize the importance of authentic healing relationships that support efforts to improve health and well-being.

Context: Complex care team members appreciate both the autonomy of the individual (including their right to determine their goals and care plan) and the importance of mutual, respectful, therapeutic relationships between individual and care team to support the individual in achieving those goals. The team members support the individual’s capacity and self-direction through the provision of discipline- and profession-specific medical and/or social expertise and access to resources.

Competency 1. Build authentic healing relationships that prioritize self-determination and encourage bi-directional feedback to inform goal setting and care delivery.

• Apply relationship-building skills incorporating safety, genuineness, and continuity to build a trusting partnership with the individual and their family.
• Demonstrate empathy and compassion in relationship-building and care delivery.
• Engage individuals in the practice of shared decision-making.
• Partner with individuals and families to provide and receive appropriate observations, reactions, and preferences to encourage and improve cooperative care.

Resources:

• Overview of care philosophies: Authentic healing relationships – A powerpoint presentation from the National Center provides a brief overview of authentic healing relationships
• Overview of care philosophies: Authentic healing relationships – A video from the Camden Coalition provides an example and explanation of authentic healing relationships
• When your symptoms don’t tell the whole story – A podcast from Marketplace on the importance of non-medical needs
• SHARE approach workshop – A modular training includes a facilitator’s guide and slides from the Agency for Healthcare Research and Quality (AHRQ) on engaging patients in their healthcare decision-making
• Engaging patients and families in their health care – A toolkit from AHRQ to help prioritize concerns and maximize interactions between practitioners, patients, and families

Competency 2. Create and maintain relevant shared care plans that reflect the goals and priorities of the individual and family.

• Foster mutual respect with the individual receiving care.
• Demonstrate an understanding of evidence-based assessment and care planning techniques to coordinate comprehensive care plans.
• Implement individual- and family-centered care planning.
• Understand processes for shared care planning across organizations.
• Examine how population characteristics and disparities and individual preferences factor into care planning.

Resources:

• Patient- and family-centered care – An article from the Institute for Patient and Family Centered Care on the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare practitioners, patients, and families

Competency 3. Partner with individuals and families to anticipate and address challenges in implementing care plans, including navigating complex systems and non-linear pathways.

• Demonstrate an understanding of how to tenaciously navigate a complex system.
• Analyze individual and structural barriers to care, including system gaps.
• Determine which prevention practices are most appropriate to implement based on analysis of barriers to care, risk assessment, and individual preferences.
• Share knowledge with individuals about their conditions and options to receive care to inform decision-making.

Resources:

• The hidden reefs: Navigating the organizational cultures of healthcare & community-based organizations for success – A powerpoint presentation from the Alliance for Strong Families and Communities on navigating the organizational cultures of healthcare and community-based organizations

Competency 4. Employ established techniques to meet people where they are, create safety, and explore behavior change.

• Identify appropriate evidence-based models of engagement and care planning based on individual characteristics, conditions, and preferences.
• Assess individuals’ readiness for behavior change with respect and non-judgement.
• Demonstrate respect for an individual’s values, needs, emotions, and readiness for behavior change.
• Support individuals in identifying opportunities for behavior change.

Resources:

• Preparing for the first primary care provider visit – A video from the Camden Coalition on supporting individuals at primary care visits
• Verbal de-escalation – A lesson plan with resources and activities from the National Center for teaching verbal de-escalation
• Duty to warn: Assessing for suicidal ideation and homicidal ideation – A presentation from the Camden Coalition to help teach assessment for suicidal and homicidal ideation
• Transtheoretical model – A video from Steven Chen on the basics of the transtheoretical model.

Competency 5. Coordinate access to social and medical care and supports with continuity.

• Identify resources, resource platforms, and strategic partners to meet an individual’s needs.
• Differentiate among care support models to appropriately refer individuals to other levels or types of care.
• Apply customized methods of communicating and partnering with other practitioners based on individual characteristics, conditions, and preferences to enable optimal care coordination and transition.
• Identify methods of engaging after a referral to appropriately sustain communication and care with the individual.

Resources:

• Determining levels of care – An article from Very Well Health on the levels of healthcare
• Knowing when a patient is ready to graduate – A video from the Camden Coalition on how to implement a warm handoff

Competency 6. Cultivate individuals’ resilience, ability, and self-efficacy in high-stakes moments and their ability to navigate setbacks, barriers, and complex systems.

• Identify the appropriate level of care to support an individual and their self-determination.
• Provide individuals with feedback on their strengths and how to use them.
• Identify opportunities for engagement with individuals during escalating situations.
• Identify appropriate teaching methods during challenges to build capacity for similar future challenges.

Resources:

• I do, we do, you do – A video from the Getty Museum to help identify the level of care appropriate to support an individual
• Giving feedback: 3 models for giving effective feedback – An overview from AUSMed on three models of giving feedback
• De-escalation, high stakes moments – A tipsheet from Crisis Prevention Institute for teaching de-escalation

Description: Complex care relies on highly functioning, collaborative care teams that coordinate across multiple settings and in partnership with individuals and families.

Context: A complex care team is most successful when its members from diverse disciplines, practices, professions, and perspectives are collaborating to support the individual in reaching their goals. Interprofessional teams support individuals with numerous, diverse, and interrelated needs by effectively integrating social care and healthcare delivery. An interprofessional complex care team also coordinates with practitioners and partners from other departments within their organization and with other organizations. The role of each team member and partner is well-defined but may also depend on the context, needs, and goals of the individual receiving care and the specialty of the team member. Complex care team members have more access to and opportunity for decision-making, leadership opportunities, and changemaking through collective leadership. Collective leadership posits that everyone on a team can and should lead. The collective leadership philosophy is based on the principles of trust, shared power, transparent and effective communication, accountability, and shared learning.

Competency 1. Understand and respect the distinct role of each care team member, including the individual and family.

• Identify the role, purpose, and function of each team member.
• Demonstrate respect for team members’ expertise and experience.
• Describe basic principles of family dynamics and family support.

Resources:

• Meaningful roles for peer providers in integrated healthcare: A guide – A toolkit from Integrated Behavioral Health Partners on how integrated care settings can hire, train, integrate, and retain health-trained peer support
• Role clarity exercise – An activity from Dave Moskowitz on facilitating and establishing role clarity among a team
• Mutual respect (presentation) – A lesson plan and presentation from HWI on the importance of mutual respect in the workplace
• Forming, storming, norming, and performing: Bruce Tuckman’s team stages model explained – A video from MindToolsVideos on Bruce Tuckman’s stages of teaming
• Virtual interprofessional learning activity – An activity from Queen’s University on the roles of interprofessional teammates

Competency 2. Develop mutual trust, support, and shared identity among care team members.

• Identify components of effective inter-professional team formation and performance.
• Identify team-building and communication strategies to foster alignment on vision/values/mission, strategic priorities, goals, boundaries, and measures of success.
• Nurture a professional identity appropriate to role and setting.
• Demonstrate an appreciation of the individual’s voice in the setting of the team’s work.
• Foster an environment in which all team members are able to challenge team decisions and structures.

Resources:

• Collective competence – A TEDxTalk on competence and communication in the context of interprofessional teams
• Just a routine operation – A video from thinkpublic on competence and communication in the context of interprofessional teams
• The ‘music’ of coordinated care – A video from the Institute for Healthcare Improvement provides an example of coordinated care and how tracking data can lead to better patient outcomes
• Interprofessional professionalism assessment toolkit – Case videos and other tools from the Interprofessional Professionalism Collaborative for implementing the Interprofessional Professionalism Assessment
• Arts based teaming scripts – An agenda and guide from the University of Utah for building and supporting a team
• TeamSTEPPS curriculum – A self-paced course from AHRQ with strategies and tools to enhance performance and patient safety
• TeamSTEPPS video toolkit – A toolkit from the American Hospital Association to improve communication and teamwork in healthcare
• Passion for the job and positive attitude  = A lesson plan and presentation from HWI on the importance of maintaining and reinvigorating passion for the job to promote job satisfaction.
• Self-confidence and workplace pride  – A lesson plan and presentation from HWI to help teach self-confidence and workplace pride.

Competency 3. Communicate clearly and directly, orally and in writing, to coordinate activities and collaborate with the individual, family, and service partners.

• Assess individuals’ capacity and preference to engage with diverse forms of information.
• Communicate orally and in writing at an appropriate complexity level for the audience.
• Identify appropriate and respectful methods of integrating technology.
• Demonstrate clear and respectful written documentation to facilitate care coordination and continuity of care.

Resources:

• Instructions for reading level exercise – An activity from the University of Pennsylvania School of Medicine to help teach the process of assessing reading level of materials
• Medical REACH to teach observation checklist – A checklist from the University of Pennsylvania School of Medicine (Joshua Kayser) and the University of Pennsylvania School of Nursing (Carolyn Cutilli) for appropriately educating patients (medical)
• Non-medical REACH to teach observation checklist – A checklist from the University of Pennsylvania School of Medicine (Joshua Kayser) for appropriately educating patients (non-medical)
• Literacy lesson agenda – A lesson plan from the University of Pennsylvania School of Medicine for teaching health literacy proficiency
• Telehealth best practices – A tipsheet from Thomas Jefferson University for teaching telehealth best practices
• Tele-social care: Implications & strategies – A guide from Rush University and the National Center on the delivery of social care activities via telephonic or virtual video-based platforms, with a focus on care management
• Information and communication technologies (lesson plan) and (presentation) – A lesson plan and presentation from HWI on how information and communication technologies can negatively influence the delivery and reception of information.
• Written communication skills lesson plan and presentation – A lesson plan and presentation from HWI on the importance of effective written communication in the healthcare setting
• Effective communication for healthcare teams: Addressing health literacy, limited English proficiency and cultural differences – A training from the CDC about health literacy, cultural competency and English proficiency
• Creating effective communication in the team – A lesson plan with activities and resources from the National Center on effective team communication

Competency 4. Employ techniques of conflict resolution, bi-directional feedback, and active listening to build, sustain, and repair relationships with colleagues.

• Identify opportunities for engagement with team members during escalating situations.
• Facilitate the prevention and resolution of conflict while preserving working relationships.
• Partner with colleagues to communicate appropriate observations, reactions, and preferences to encourage and improve cooperative care.
• Apply skills of active listening including focusing completely on the speaker, understanding their message, comprehending the information, and responding thoughtfully to improve mutual understanding.

Resources:

• Conflict management – A lesson plan and presentation from HWI for teaching the dynamics of conflict and how to effectively manage conflict
• Crucial conversations – A training from VitalSmarts on carrying out crucial conversations to communicate effectively
• Effectively giving and receiving feedback (presentation) – A presentation from HWI on the purpose of feedback and strategies for how to effectively give as well as receive feedback.
• Interpersonal oral communication (presentation) – A lesson plan and presentation from HWI with techniques for the development of effective interpersonal and oral communication skills.
• Small group communication skills (presentation) – A lesson plan and presentation from HWI for teaching how supportive communication patterns help to create and negotiate responsibilities by building trust and respect.
• Listening (lesson plan) and (presentation) – A lesson plan and presentation from HWI on the basics of what to do before, during, and after engaging in active listening.
• Nonverbal communication (presentation) – A lesson plan and presentation from HWI on nonverbal communication for improved communication competency — including paralanguage, body language, gestures, and physical space

Competency 5. Contribute to collaborative decision making and collective leadership.

• Use person-centered collaborative care with interdisciplinary teams.
• Apply shared decision-making principles related to interdisciplinary teams to meet shared goals.
• Foster an environment of trust, mutual respect, and humility to facilitate collective leadership.
• Contribute skills and perspective to inform team goals and success.

Resources:

• Building an effective collaborative team (presentation) – A lesson plan and presentation from HWI on working effectively in interprofessional collaborative teams to improve the quality and safety of patient care.

Description: Complex care team members collect and use quantitative and qualitative information, including from the individual and their family, to identify clients, assess needs, adapt best practices, and continuously improve the delivery of care and supports. The term “information” includes both quantitative and qualitative data, including stories that derive from a variety of sources.

Context: As complex care is in a formative stage, the field needs to develop knowledge through research, quality improvement, and evaluation. Complex care also should look to adapt best practices from more frequently studied interventions for populations without complex needs. At the individual level, complex care promotes the integration of whole-person information. At the systems level, integrating cross-sector information allows team members to identify individuals who need the most support and to collaborate to address their specific needs, maximizing impact and improving outcomes across systems.

Competency 1. Understand best practices in gathering, documenting, and sharing individual-level information, and the impact of bias inherent in those processes on the delivery of care.

• Understand the impact of unconscious bias on data collection and distribution.
• Demonstrate methods of meaningful, trauma-informed, and person-centered data collection, documenting, and sharing.
  • Demonstrate ability to respectfully educate individuals on their rights and the risks of sharing information.
  • Demonstrate ability to elicit individual preference for how and when information is shared.
• Identify ethical, legal, and regulatory requirements of data collection and storage to ensure compliance and minimize impact on individuals.

Resources:

• Toolkit for communities using health data: How to collect, use, protect, and share data responsibly – A toolkit from HHS for collecting, using, protecting, and sharing data responsibly
• HIPAA tip sheet – A tip sheet from Thomas Jefferson University on data privacy
• HIPAA training video – A video from the Camden Coalition on HIPAA regulations
• Uncovering and removing data bias in healthcare – An article from Healthcare Information and Management Systems Society on biases in data
• Social media and technology (presentation) – A presentation from HWI on how to engage in professional online boundary management to ensure that public and private use of social media uphold HIPAA standards and do not lead to violations
• AHRQ’s making informed consent an informed choice: Training modules for health care leaders and professionals – A training module from AHRQ to help teach clear, comprehensive, engaging communication strategies that hospitals and clinical teams can use to ensure that people understand the benefits, harms, and risks of their alternatives, including the option of not having any treatment

Competency 2. Assess the root cause of individual health needs and population disparities to inform care, programmatic, and systems-level decisions.

• Analyze the complex systems surrounding individuals to identify needs.
• Analyze the complex systems surrounding populations to identify reasons for health disparities.
• Apply knowledge of key needs and reasons for health disparities to inform care delivery and programmatic and systems-level decisions.
• Demonstrate ability to define a root cause and conduct a root cause analysis.

Resources:

• Conduct a three-part data review to understand patient needs – A guide from the Better Care Playbook to understanding patient needs through empirical data
• Mapping community supports for patients with complex health and social needs – A guide from the Better Care Playbook to map community support
• Asset and partner mapping template and instructions – A guide and template from the National Center to map assets and partners
• Root cause assessment – A worksheet from the National Center for assessing root causes of need
• Healthcare disparities – A course on healthcare disparities from MedEdPORTAL on increasing awareness about racial and ethnic disparities across the spectrum of healthcare services and examining the use of patient-centered communication skills to minimize these disparities
• Structural competency: Curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities – Curriculum from MedEdPORTAL on identifying and understanding the structural factors that produce health disparities
• Roots of health inequity course – A course from the National Association of County and City Health Officials on addressing systemic differences in health and wellness that are actionable, unfair, and unjust

Competency 3. Carefully evaluate and implement the current available evidence base to inform care appropriate for each individual’s context, as well as programmatic interventions and systems-level policy.

• Demonstrate knowledge of current research and promising practices related to methods of engagement, care planning, and care delivery.
• Evaluate the value and limitations of evidence-based practices to care delivery across all environments and contexts to provide optimal care.
• Use evidence-based and promising practices to inform individual practice.

Resources:

• What is evidence-based practice? – A case study and guide from the University of Utah on identifying and evaluating evidence-based practices
• One size does not fit all: How to adapt evidence-based interventions to fit local contexts and maintain fidelity – A presentation from the Penn Center for Community Health Workers on the adaptation of evidence-based interventions to fit local contexts and maintain fidelity
• Will it work here? A generalizability framework for applying evidence from impact evaluations in new contexts – A presentation from J-PAL on how to adapt interventions for new settings and populations based on the local culture
• Adapting evidence-based interventions for new populations and settings – A course from Region 2 Public Health Training on how to adapt interventions for new settings and populations based on the local culture
• Making adaptations tip sheet – A tipsheet from Family and Youth Services Bureau for making changes to evidence-based practices so that they are more suitable for a particular population or setting

Competency 4. Continuously collect, use, and evaluate information to drive resource allocation, improve the quality of care, and improve team member experiences in delivering that care.

• Identify core principles and practices of quality improvement science.
• Analyze information to inform tactical decision making.

Resources:

• Quality improvement science the basics #1
• Quality improvement science the basics #2
• Quality improvement science the basics #3 – A three-part video series from HealthQuality Ontario on QI science
• Data-driven decision making: A primer for beginners – An information guide from Northeastern on how to drive healthcare decision-making.

Competency 5. Disseminate lessons, resources, and best practices to individuals, colleagues, community partners, policymakers, and others in the field.

• Identify methods of sharing available knowledge, emerging best practices, evidence, and research in an accessible manner with various stakeholders.
• Identify methods of interpreting findings and information for various audiences and uses.

Resources:

• Written communication skills (presentation) – A lesson plan and presentation from HWI to help teach the importance of effective written communication in the healthcare setting
• Audience adaptation – An article from the University of Pittsburgh’s Department of Communications on how to identify an audience and adapt materials to their interest, level of understanding, attitudes and beliefs

Description: Individuals with complex needs interact with multiple — often incongruous — systems that can each present barriers to improving health and well-being. The complex care workforce analyzes individual problems from a systems perspective and advocates for systems reform and policies that foster whole-person health.

Context: Complex care team members understand that individuals’ opportunities for health and well-being are determined in part by the interplay of multiple actors (e.g., political, community, environment) within systems including healthcare, human services, and public health. Care team members operate within existing systems while also working to improve those systems through collaboration, coalitions, and advocacy. Team members support individuals in creatively navigating and problem-solving within these systems. Team members often become liaisons between their organization’s policies and systems and the individuals with whom they are working. Cross-system operational and cultural literacy allows team members to collaborate and coordinate services to better meet the diversity of health and social needs.

Competency 1. Understand essential elements of healthcare, human services, and public health sectors and strategies for sharing information and integrating service delivery across sectors.

• Develop understanding of relevant health and social care systems and their associated barriers and challenges.
• Analyze standards of practice across industries to apply professional behavior and effective communication practices.
• Demonstrate ability to translate and transmit information across sectors.
• Cultivate relationships and knowledge to build collaborative care efforts.

Resources:

• The hidden reefs: Navigating the organizational cultures of healthcare & community-based organizations for success – A powerpoint presentation from the Alliance for Strong Families and Communities on navigating the organizational cultures of healthcare and community-based organizations
• Introduction to healthcare – A course from Coursera on the fundamentals of the US healthcare system, including an overview of the principal institutions and participants in healthcare systems and the interactions between them
• Introduction to the healthcare system A course from the Patient Navigator Training Collaborative on the basics of healthcare systems for new healthcare workers
• Introduction to the nonprofit sector, nonprofit organizations, non profit leadership and governance – A course from Coursera on the nonprofit sector, nonprofit organizations, and the concepts of leadership and governance
• Introduction to public health – A presentation, course, and webinar from the CDC on public health
• Public health 101 – Courses from the CDC on the fundamentals of public health and the core sciences of public health practice
• Discovering value-based health care – A course from the University of Texas at Austin Dell Medical School that helps you understand and implement value-based care

Competency 2. Understand basic elements of the local, state, and federal civic processes.

• Identify the stakeholders, roles, structures, and processes of local, state, and federal government entities.
• Identify the processes through which civic entities affect care delivery and the environment in which it exists.

Resources:

• How a bill becomes a law – A video from Govtrack on how a bill becomes a law
• Social policy for social services & health practitioners specialization – A course from Coursera on the size, structure and outcome of US social policy
• Public health law  – A training plan from the CDC on the use of law and policy to improve population health outcomes
• What is policy analysis? – A presentation from the Camden Coalition on civic process and policy-making
• Health administration and policy – A presentation from the Camden Coalition on national health administration

Competency 3. Collaborate and organize with members of the health and social sectors and with community members to build and maintain coalitions and collaborative structures.

• Identify strategies to engage, develop, sustain, and grow community relationships.
• Develop strategies for communication, collaboration, and relationship building among interprofessional teams to maximize team effectiveness and challenge traditional professional boundaries and structures.
• Collaborate with community partners in identifying the source of challenges, setting goals, developing an action plan, considering possible outcomes, and implementing the action plan.

Resources:

• Concept mapping: Navigating the learning process – An article from the NIH on concept-mapping
• Introduction to the family engagement in systems assessment tools (presentation) and Video – A slide deck from Family Voices on engaging families to build coalitions and change systems
• Power of partnership in transformation – A video from the National Center that provides a real life example of patients, caregivers and systems working side-by-side to transform the patient experience
• How to turn a group of strangers into a team – A TEDx Talk about the elements of a team
• How to lead a collective impact working group: A comprehensive toolkit – A toolkit from the Collective Impact Forum for facilitating teamwork across sectors

Competency 4. Use collective power, privilege, and access to question the status quo and advocate for policy change.

• Understand and leverage self and team positionality related to power, privilege, and oppression and how that positionality influences work with the community and with the targets of advocacy (e.g., decision-makers).
• Identify and question long-standing or normed policies and practices in programs, organizations, and systems that are not benefiting individuals with complex needs.
• Identify methods of influencing decision-makers to implement lasting change.

Resources:

• Messaging health equity to decision-makers – A webinar from the Northwest Center for Public Health Practice includes strategies for messaging health equity to decision-makers to ensure under-resourced communities have access to the new programs and funding created by a policy
• Policy briefs: From plan to action – A course from the Northwest Center for Public Health Practice on organizing your thinking, strategizing and communicating about action items, and proposing changes to policies that affect your community
• Critical thinking (presentation) – A lesson plan and presentation from HWI on the importance of critical thinking in the healthcare environment.
• Learning from parallel populations – A video from the National Center about other social movements that are a model for the field of complex care
• Tips for advocates: Decision-maker advocacy – A guide from Community Catalyst on advocacy.

Competency 5. Inform others’ understanding of challenges and potential systems-level solutions by synthesizing personal narratives and aggregating information.

• Consult with communities affected by specific challenges to understand their views and experiences, with attention to economic, social, and cultural perspectives.
• Collaborate with individuals to prepare written and multimedia materials that explain how systems-level and environmental factors cause or exacerbate the harm they experience.
• Authentically center and amplify community voices to educate and influence decision makers, legislators, and policymakers.
• Identify methods of communicating stories and other information to influence a targeted audience.

Resources:

• Who tells the story? – A guide from Kate Marple on strategies, considerations, and tools for storytelling
• Storytelling framework – A framework from the San Mateo County Office of Diversity and Equity with strategies, considerations, and tools for storytelling
• Storytelling template – A template from the CDC with strategies, considerations, and tools for storytelling

Competency 6. Recognize and adapt to the current processes and structures of organizations, systems, and policies while seeking to effect positive and aspirational change.

• Analyze how organizational hierarchy, policies and procedures, and personnel resources both contribute to and hinder the organization achieving its mission and vision
• Use leadership, professionalism, and emotional intelligence to assess interpersonal, organizational, and system-level dynamics and select the appropriate approach to effect positive change
• Advocate internally for organizational policies, processes, and structures that reduce harm and increase the quality of care delivery and team member wellness

Resources:

• Escape fire – A film on the powerful forces that maintain the status quo
• Workplace health promotion model – An overview from the CDC helps encourage workplace health promotion
• Emotional intelligence lesson plan and presentation – A lesson plan and presentation from HWI on emotional intelligence, assessments of emotional intelligence, and strategies to improve emotional intelligence