Collaborative care has risen in popularity in recent years and now is viewed as an important component of public health. Collaborative care utilizes the resources of the community to enhance health outcomes and reduce a multitude of health problems. It leverages the unique strengths of different organizations to create better patient outcomes and, ultimately, a healthier community. This article describes how community partnerships work, and the benefits of collaborative care, and highlights some real-world examples of successful collaborative care models.
What is Collaborative Care?
Integrated care is an approach that organizes person-centered care and support services to achieve the best outcomes for individuals. In many countries, the traditional way of providing health and social care responses has been to offer silo services with limited coordination vertically or horizontally. Often a person’s journey through the health and social-care systems follows parallel and disconnected pathways that don’t link up, moving from one service to another without interconnection or clear transitions. Collaborative care involves purposefully planning and delivering healthcare services and community resources for individuals using a person-centered integrated approach. The care and support provided need to recognize the whole person, their environment, and social and emotional needs while respecting individual choice and autonomy.
The Importance of Community Partnerships
Community partnerships are the foundation of collaborative care, and this includes identified stakeholders such as:
- Healthcare Providers: Physicians, nurses, and specialists who offer medical care and guidance.
- Public Health Organizations: Entities focused on disease prevention, health promotion, and community well-being.
- Non-Profit Organisations: These are the support services of provide shelter, food, and mental health counselling.
- Government Agencies: Local and state departments that offer funding, policy support, and regulatory oversight.
- Community Leaders: Community members or groups of people who identify local needs and can support people to get involved.
Pooling budgets and know-how, they confront health problems more effectively than any one of them might on its own and offer more context-sensitive, resilient strategies to tackle public health challenges.
Benefits of Collaborative Care
Comprehensive Care Delivery
An important consequence of this collaborative approach is comprehensive care. People often need help in many areas related to their physical and mental health. For instance, someone with diabetes may benefit from medical care, as well as specific nutrition recommendations and assistance in stress-management techniques. If healthcare providers work together, it can improve the overall health outcomes for a given patient.
Improved Access to Services
Collaborative care models can facilitate access to services, especially for underserved populations. Communities are key – those familiar with a neighborhood can help to fill service gaps. A community health worker, for example, might assist a patient in accessing the healthcare system, transportation, or affordable medications.
Enhanced Patient Engagement
Coordinated team care increases patient engagement while also improving patient satisfaction with the care received. Patients who are more satisfied with their support networks – ranging from doctors to family, friends, and even pets – are more likely to stick to their care plans, which is especially important for long-term health. Collaborative care allows the patients to become active – rather than passive recipients – of their care. Many patients have complex conditions and multiple chronic illnesses. As a team, clinicians are better able to piece together the unique care puzzle for each patient and formulate a plan for managing these complex, unique care situations.
Efficient Use of Resources
Collaboration also enables the efficient use of resources by ensuring nobody is duplicating services or investments unnecessarily. An example of this type of collaboration could take place if local clinics share patient information with a community health initiative to assess which populations would most benefit from interventions.
Addressing Social Determinants of Health
Many also provide access to other services that foster healthy behaviors, address social determinants of health (eg, housing, education, employment, economic stability), and generally support wellbeing. By employing persons involved in community organizations that provide these services, collaborative care models reach beyond the limitations of medical care to address broader determinants of health.
Examples of Successful Collaborative Care Models
The Accountable Care Organization (ACO)
For instance, participating in Accountable Care Organisations brings together hospital systems, primary care physicians, and specialists to coordinate care to benefit both patients and the healthcare enterprise by providing care that gives equal attention to quality and cost. Individually, no group of healthcare providers could fully grasp the value of this unappreciated resource, but together they can create integrated systems of information that allow healthcare providers to work together and combine forces to produce better patient-centered care at lower cost.
Community Health Worker Programs
CHW programs show how community-based partnerships can benefit health outcomes CHWs are members of a community who serve as a liaison between providers of care and the patients they serve. Growing out of philanthropic organizations, such as the US missionary movement, and community mental health programs in the 1960s, CHWs are now a common component of healthcare delivery systems around the world. Training often takes place on-the-job, rather than in an academic setting, and CHWs commonly hail from the populations they serve. Their role is to support, connect, educate, and advocate for the people in their community, particularly those facing health, emotional, environmental, or social problems where care falls through the cracks or is inadequate. These programs can improve access to care, enhance treatment adherence, reduce costs, and, most importantly, help overcome some of the deep health disparities that plague our health systems.
The Patient-Centered Medical Home (PCMH)
The Patient-Centred Medical Home model involves a holistic and coordinated approach to care, centered around the patient. PCMHs bring together an entire care team working towards the management of a person’s healthcare needs. Often, they foster strong relationships with community resources to support social determinants of health. This model is focused on building a robust partnership between the provider and the patient.
Integrated Behavioral Health Models
They combine mental health and primary care services into what are known as ‘integrated behavioral health models’. A typical possible scenario might take place in a primary care clinic. With an integrated model, mental health professionals might become part of staff members at the clinic, available on-site, to provide counseling to some portion of that clinic’s patients.
Challenges and Considerations
Although collaborative care can have many benefits, it is not easy. It requires clear communication among partners in care, shared goals, respect for other partners’ time and abilities, and mutual interest in the client’s well-being. Understanding each partner’s bottom line and motivations helps to make collaboration effective. Some of the main challenges to an effective collaborative approach so far include:
Coordination and Communication
Making sure everyone involved in care is on the same page and on track can be difficult, which could inadvertently lead to holes in care delivery or different information for the same patient from different sources.
Funding and Resource Allocation
Collaborative care models require significant resources, which can be difficult to secure. Partners will need to work together to ensure that resources are used effectively and fairly.
Cultural and Organizational Differences
Organizations and other stakeholders will have differing goals, priorities, ways of working, and cultures; this needs to be cajoled, negotiated, accepted, and, ideally, appreciated in the interests of advancing common goals.
Data Sharing and Privacy
Sharing patient information between schemes could lead to challenges in privacy and data safety. Robust protocols for data management need to exist along with compliance with required legislation.
Future Directions for Collaborative Care
Given the current trend in healthcare, collaborative care models are likely to continue to rise in prominence. One model of such care in the future may be:
Enhanced Technology Integration
Technology can also help to facilitate coordination and information sharing between partners. For example, partners can use electronic health records (EHRs) and telehealth tools to help flatten the care delivery curve (among many other community benefits).
Increased Focus on Health Equity
A focus on health disparities and health equity will be a natural component of collaborative care models of the future. Strategies for partnership should increasingly target the unmet needs of our underserved populations, where the principal social determinants of health are manifested.
Expansion of Community-Based Initiatives
There will likely be a greater emphasis on community-based initiatives, which will involve partnerships between large organizations and smaller, community-based entities ranging from mobile health clinics to community wellness programs.
Policy and System Changes
We envision, and indeed support, modifications in healthcare policy and systems that facilitate these collaborative care models. Advocating for a policy that supports integration within organizations and systems, that funds and supports community partnership programs, will be a core element of advancing collaborative care in the years to come.
Collaborative care can revolutionize public health by utilizing community partnerships to help achieve health goals. Integrating services through healthcare provision, addressing social determinants of health, and coordinating stakeholder participation create an accessible, adaptable, and efficient approach to care. It has the potential to make communities healthier to slow disease regression and prevent illness in critical populations. Although no one solution can ‘fix’ everything or accelerate stable returns for multiple stakeholders, community-driven collaborative care programs show promise in achieving more positive and sustainable health outcomes in the context of long-term chronic illness.
