As a community, aligning efforts across a community to support the
safety and well-being of vulnerable and underserved individuals is
extraordinarily difficult. These individuals suffer
disproportionally from health issues, job loss, a lack of stable
housing, high utility costs, substance abuse, and homelessness. In
addition to medical care, these individuals often critically need
access to community social sector organizations that provide a
distinct and complementary set of services, such as housing, food
services, emergency utility assistance, and employment assistance.
These services are just as vital as healthcare services to these
individuals' long-term health and well-being, with data suggesting
that 80-90% of health outcomes can be attributed to factors beyond
direct medical intervention. This book proposes a novel approach to
the coordination of medicine and social services through the use of
people, process, and technology, with the goal being to streamline
coordination between medical and Community-Based Organizations and
to promote true cross-sector patient and client advocacy. The book
is based on the experience of Dallas, TX, which was one of the
first metropolitan regions to develop a comprehensive foundation
for partnership between a community's clinical and social sectors
using web-based information exchange. In the 5 years since the
initial launch, the authors have been able to provide seamless
connection, communication, and coordination between healthcare
providers and a wide array of community-based social service
organizations (a/k/a Community-Based Organizations or CBOs),
criminal justice entities, and various other community
organizations, including non-collegiate educational systems. This
practical how-to guide is the codification of transferrable lessons
from successes and challenges faced when working with clinical,
community, and government leaders. By reading this playbook,
leaders interested in building (or expanding) connected
clinical-community services will learn how to: 1) facilitate
cross-sector care coordination; 2) enable community care partners
to better provide targeted services to community residents; 3)
reduce duplication of services across partnering organizations; and
4) help to bridge service gaps in the currently fragmented system.
Implementation of services, as recommended in this book, will
ultimately streamline assistance efforts, reduce repeat crises and
emergency funding requests, help address disparities of care, and
improve the health, safety, and well-being of the most vulnerable
community residents.
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