By Carter Wilson, Associate Director for the National Center, and Rebecca Koppel, Program Manager for Field Building & Resources

Individuals with complex health and social needs are particularly vulnerable during a pandemic like COVID-19. Many have compromised immune systems, crowded living conditions, and jobs that either require them to work out of the home or are early losses in the economic downturn. In the current epidemic, programs that serve these individuals have had to rapidly adapt their operations to meet the growing and changing needs of this population. A redesign of services is required to address the emerging needs that the pandemic has indirectly created. Existing operations needed to quickly pivot to dramatically reduce in-person interactions. And new collaborations are necessary to inform, support, and deliver these interventions.

Last year, the National Center launched a working group of 15 individuals tasked with defining the front-line competencies for the field of complex care. The group was diverse in profession, care setting, and geography, but all were actively working in programs supporting individuals with complex health and social needs. The National Center interviewed members of the core competency working group to learn the challenges they were seeing and how they were overcoming them. The result is a series of blog posts highlighting their stories. Click the links below to navigate through the series:

• Innovating and adapting to new services, populations, and opportunities
• Switching to virtual care delivery
• Finding and leveraging partnerships

A cooperative, community-level response is necessary for ensuring efficient and effective service delivery, particularly for those that have numerous and interrelated needs. Doing so during a pandemic is challenging. As the saying goes, “If you want to go fast, go alone. If you want to go far, go together.” With COVID-19, we needed to go far fast. Here’s how the providers we talked to used new and existing connections to better respond to the needs of vulnerable community members.

Coordinating community health worker outreach in the Midwest

Jodie Sevier is an Iowa-based community health worker with MercyOne, a Clinically Integrated Network of 420 hospitals, clinics, and other health care facilitates. In this role, she supports universal screening for social determinants of health and is responsible for following up with patients who identify a need and request assistance. Once COVID-19 hit, what was routine work for the community health workers unexpectedly changed. Community health workers transitioned from primarily responding to in-clinic screening to proactively reaching out to screen high risk patients telephonically. To meet the growing needs for their services, Jodie and her colleagues quickly leveraged new and existing partnerships.

This started from within Iowa’s MercyOne community. Another area of the state, Waterloo, was struggling to respond to a coronavirus outbreak, home to a Tyson meat packing plant that was impacted early. The MercyOne team in North Iowa quickly leaned in and helped support outreach and navigation. Relationships with outside organizations such as public health were also strengthened. Collaboration was necessary to ensure efforts from both the healthcare system and public health were complimentary rather than duplicative.

Throughout it all, Jodie found community in an informal network of community health workers, both within MercyOne and beyond. Pre-COVID, she participated in a community health worker training with peers based in Kentucky. They agreed to stay in touch, connecting once a month for 30 minutes to keep each other abreast of activities. With COVID, they realized there was much greater opportunity to support one another as they found new ways to serve their patients. Community Health Workers from CommonSpirit Health in Colorado and Nebraska were also brought in. The monthly half hour calls quickly became hour-longs calls every Friday, pulling together community health workers from four states. For each call, Jodie asks herself, “How are different programs doing what I do? And how could we improve daily in our work doing it differently, better?”

Community-based organization collaboration in New York

In addition to her role as Assistant Professor at the New York University Rory Meyers College of Nursing, Tina Sadarangani leads a local nonprofit in her home town in Westchester County, NY, just a mile away from the original epicenter of New York’s outbreak. Her group, founded in 1997 with the motto of “Neighbors helping neighbors,” was designed to provide families with dependent children living in her socioeconomically diverse district with financial and emotional support when faced with a serious illness (e.g., cancer) or sudden death of a parent or child. Assistance ranges from short-term financial support with rent when illness prevents a family member from working to simple home cooked meals from neighbors to ease the burden of putting dinner on the table in a crisis.

Early into the pandemic it became clear that COVID-19 would not be the great equalizer. Illness and unemployment disproportionately affected Hispanic members of Sadarangani’s community – many of whom were essential workers who could not shelter in place or domestic workers with few employment protections. A significant portion of her immigrant neighbors were undocumented and therefore ineligible for support from the CARES Act.

It became clear to Tina and other community members who led other local nonprofits, such as the local Hunger Task Force, the Community Resource Center, and the School Board of Education, that the pandemic had exacerbated many families’ needs. Yes, people were getting sick. But many, many more were facing food insecurity, unemployment, strained mental health, and isolation. With schools closed, more needed to be done to ensure the children and families in the most vulnerable households were having their basic needs met. As one School Board member said, “We need to stop operating as a district and start operating as a community.”

Leaders of these groups and many others joined together to understand how they could align and coordinate services to ensure services were not being duplicated and to make sure every family’s needs were addressed comprehensively. Everyone from school social workers, clinicians, mental health workers, the local STEM alliance, and members of the Hunger Task Force formed a coalition to understand how they could use their resources and volunteers to meet the evolving needs of community members. High-risk areas were identified and targeted for distribution of masks, hand sanitizer, and bilingual pamphlets (designed by the STEM alliance) with instructions on what to do if a family member is sick. The needs of households were assessed holistically, with each organization leveraging their individual strengths to meet household needs.

One of the clearest examples of working collaboratively as a community came with respect to addressing food insecurity. The Hunger Task Force reported a line of 800 cars at their weekly food distribution and only had resources for 600. Simultaneously, local restaurants were shutting their doors because of lack of business and the Community Resource Center reported an on-going need for food and supplies among Hispanic community members. With the support of the coalition, Sadarangani used her meal train volunteers to purchase meals from local restaurants and have them delivered to families facing hunger. Both restaurants and families benefitted.

Prior to the pandemic, getting this many community leaders at a table together seemed impossible. However, COVID-19 brought a sense of urgency that fostered innovation and collaboration around key problems associated with the pandemic. The community needed any and all of its resources to support its families and no single organization could address the complexities associated with COVID-19. Everyone had and continues to have a role to play. The key lesson was that organizations need to work, think, and act in new ways to promote equitable and inclusive communities. Even as restrictions lift and individuals return to work, the coalition, informed by the unprecedented experiences that COVID-19 has brought, will continue its work and use its momentum to identify shared solutions to some of the most challenging issues in Tina’s community.