It takes an ecosystem: Finding success in complex care

Kathleen Noonan

Strengthening ecosystems of care

Read the adapted opening remarks by Kathleen Noonan, CEO of the Camden Coalition for Healthcare Providers, for Putting Care at the Center 2019. The conference is hosted by the National Center for Complex Health and Social Needs, an initiative of the Camden Coalition, and was held in Memphis, TN.

Welcome to the fourth Putting Care at the Center Conference. We are so excited to be here in Memphis as we work together to build the field of complex care.

The Blueprint for Complex Care, released at last year’s conference, borrowed from the language of environmentalists in calling for the creation of complex care ecosystems interconnected groups of organizations shaping the environment around us. In the field of complex care, our ecosystem includes consumers and families, health systems and practitioners, public health thinkers and doers, social service organizations, educators, first responders like police and fire, and more. Each of us is vital to this network.

Core to an ecosystem is interdependence from small community-based non-profits to large hospital networks. Interdependence is, in fact, the strength of ecosystems and in this complex care movement we’re advancing, it’s the key to our collective success.

Also key to our success is cherishing the idiosyncratic nature of local ecosystems we’ll call them microclimates. As all gardeners know, while growing conditions differ from place to place, we all want to see the garden bloom. Real interconnectedness requires real authenticity between and among patients, helpers, and communities. The most powerful examples of successful complex care ecosystems feature local and regional communities coming together, honestly evaluating their systems, understanding who’s at the table, and identifying who’s missing and marginalized. This is the hard work of building authentic, healing relationships and it’s absolutely necessary.

So why do we talk about ecosystems?

At the Camden Coalition, which houses the National Center, we’re working alongside partners regionally and across the country including Regional One Health right here in Memphis to co-design models that honor and strengthen local ecosystems. These ecosystems don’t feature a single organization or system, but rather a diverse group of stakeholders. Indeed, Regional One’s efforts may have started within the walls of a hospital, but they thrived in the community centers, houses of worship, libraries, and clinics of Memphis.

So while complex care ecosystems necessarily include backbone organizations like anchor hospitals, they flourish when informal networks come to the table faith communities, recovery and support groups, and families. It is these informal networks that are the most consistent in our own lives and the lives of the individuals we serve. They’re invaluable partners in the work of helping others.

As a field, while we talk a lot about what’s needed in ecosystems, we need to talk a lot more about how to make them work. That is where people who study the play of children can offer some insight.

People who study child play call one of the early stages of play “parallel play.” This is the phase of development where children can be observed simply playing side-by-side.

This is where our most of our complex care ecosystems are now. We’re looking at what others are doing and may even mimic a peer’s efforts, but we’re not cooperating certainly not all of the time.

Where we want to get is closer to a game of double-dutch, which child play experts call “cooperative play.” In cooperative play, the activity is organized, and participants have assigned roles, including a leader who makes sure everyone knows the rules and may even engage in some useful conflict resolution.  Importantly, in cooperative play, there is a palpable sense of group identity.

So how do we compel organizations and partners to move to this place of cooperative play?

Sometimes, it’s the simple things.

I heard a story years ago when co-location was all the rage a library, a recreation center, and a health center all set up shop in the same building. And yet a year after everyone was in the same space, there were still few joint activities.

Why not?

For one, no one’s job description had changed. No one at the recreation center had an obligation to meet with the health center. The health center staff weren’t expected to engage the library, and so on. Turns out, something as simple as a revised job

To be sure, it’s not always as simple as updating a job description (though updating a job description isn’t always simple). There are big, complicated issues to tackle in order to develop the ecosystems we want, and in the context of person-centered health and authentic healing relationships that we need.

First, we have to move away from using avoidance metrics as the only way we measure our success in helping people with complex needs. We can’t see our full impact on individuals’ lives if the only outcomes we report are how well we reduced the number of emergency department visits, the number of inpatient stays, and costs. We have to measure

>total health reductions in symptoms and disease, well being, self-efficacy, and improved relationships and social conditions.

Second, while evidence-based interventions are essential to creating a strong field of complex care, we need to broaden our focus. Research and evidence is critical, but we also know that communities want (and need) to co-design ecosystems in ways that may not have existing, rigorous evidence bases. Communities often draw on their own experiences to create programs that respond to their specific needs, pressures, and histories. So as our field pursues vital, longitudinal research, let’s also empower our partners and their workforces with the resources, training, and support to develop and implement community-responsive models that move the needle in ways that may not be as quantifiably measurable in the short-run.

It’s critical to note that some of the hardest jobs in our complex care ecosystems fall on workers with the fewest resources. And it’s the responsibility of institutions with more to address that privilege gap. If we expect all those in our ecosystemsbig and small to equitably participate, then we need to make sure they’re equitably resourced. This includes fair pay.

Third, we need to acknowledge that even when we, in the health and social services space, are able to make changes in our sphere of influence, there are structural and policy issues that are outside our individual capacity to reform, but essential to improving health. So as we address what’s in our control, we need to candidly, vocally acknowledge those things that we need help with, and work together to make the systemic changes that will help our ecosystems thrive. That means engaging city, county, state, and federal government partners, for example, in developing a vision to close gaps in access, improve care delivery, lift regulatory barriers, and optimize technology solutions.

Finally, we need to listen to consumers, especially persons with complex health and social needs. They know firsthand the system misalignment, community disinvestment, and lack of resources that we’re trying so hard to fix. They have lived experience and deep conviction that make them uniquely able to speak to the issues plaguing our ecosystems and to help craft new solutions — to bring our field from parallel play to cooperative play.

In fact, consumers are the very heart of this ecosystem.

Coretta Scott King, whose wisdom and memory is forever tied to this great city, once said that, “The greatness of a community is most accurately measured by the compassionate actions of its members.” As we work together to deepen our understanding and practice, I want to thank you for your compassionate actions to ensure that every member of our ecosystem is seen and heard and healed.

Thank you.