Addressing barriers to care in metro Atlanta

Strengthening ecosystems of care SDOH & health equity

By Alex Lipira, Program Assistant for Field Building and Resources

The Blueprint for Complex Care highlighted the need for more local connectivity to create coordinated care for individuals with complex health and social needs. The National Center developed the regional complex care convenings project in response to act as a catalyst for local communities facing barriers to complex care.

One of the three selected host organizations was the Atlanta Regional Collaborative for Health Improvement (ARCHI), a coalition of public, private and nonprofit organizations committed to improving health outcomes in the metro Atlanta area. Led by Executive Director Kathryn Lawler, ARCHI described their community barrier as a disconnect between patients and social services in the metro Atlanta area despite having a rich network of healthcare systems, a safety net system, multiple FQHCs, and community health systems. 

They found that patients were having difficulty navigating the social services that can address the symptoms and oftentimes the drivers of their complex medical needs. Providers didn’t have access to real-time availability of services or the ability to make real-time referrals. Even when referrals were successful and services were received, there wasn’t a way to share data between providers.

Laying the groundwork

To lay the groundwork for the regional convening in the Atlanta community, ARCHI and the National Center decided to use both an existing meeting and a smaller scale workshop to explore the field of complex care and the opportunities to expand services.

ARCHI’s September 11 quarterly meeting included a high-level overview on complex care and national best practices followed by a panel of community health workers who shared their patients’ perspectives on navigating care. Georgia state officials highlighted strategies for policies and programs to advance and improve complex care. Table discussions challenged attendees to think about the individuals their organizations serve, identify their complex care challenges, and brainstorm current efforts and aspirations to improve care.

On November 7, ARCHI brought together direct service providers from 20 healthcare and social service organizations for a deep dive on collaborating across sectors. After hearing from Sooner Health Access Network in Oklahoma about their innovative solutions to improve care for their populations, attendees discussed the need for a shared data platform between health and social services to ensure care coordination for shared patients.

Throughout 2019, ARCHI worked with their network partners to better understand the social needs of their patients, particularly food access, transportation, and affordable housing. While planning the regional convening and the two preceding events, ARCHI launched pilots in a local safety-net hospital and federally qualified health center with staff connecting patients to community-based organizations providing these services. The pilots continue to highlight the importance of connectivity between agencies and the need for data sharing that does not require double entry or increased administrative burden. 

While the pilots have had to pivot in response to the COVID pandemic, the legal agreements, data sharing protocols, and personal relationships between agencies have made it possible to move the pilots from clinic-based to a largely telephonic set of services to reduce the spread of the virus.

Convening to create change

On December 11, ARCHI brought together individuals actively working in complex care and senior leaders from major health systems for its regional convening, which opened with a conversation on the value of community health workers in the patient journey. Six health system and insurance CEOs shared how complex needs emerge in the patient populations they serve, their programs for addressing social determinants of health, and their ideas about improving the infrastructure of care. 

The regional convening culminated with the six health system leaders making a commitment to recognize affordable housing as a critical social determinant. Each of the six health leaders signed a public statement about the connection between health and housing, committing to work collaboratively to fund affordable housing initiatives as representatives from local housing organizations stood in support.

Strengthening the connection

ARCHI used these three complex care convenings and the data-sharing pilot project to bring together partners across sectors to improve care coordination between social and clinical services in metro Atlanta. The participation of health systems, payers, and community organizations was a true testament to the power of breaking down silos and building up collaborations between sectors to address complex health and social needs of individuals in Atlanta.

Though 2020 has turned out to be a very different year for advancing complex care work than the ARCHI organizers originally envisioned, several things remain true and are even more important now. First, the Atlanta area must find ways to shift the burden of navigating between different services, supports, and sectors away from the patients and clients who are experiencing vulnerabilities and onto the system of care itself. As the metro region grapples with the changes in access, intake, care coordination, and service delivery that this will entail, it must also center race, centering the needs of those who have experienced historic and persistent inequities. Second, that despite its challenges, collaboration builds incredible resilience among organizations, allowing them to pivot in real-time to meet changing and critical needs.