Journey to connection
Research shows that when patients receive the social resources they need, hospital admissions can be reduced and overall health can be improved. By documenting and tracking a patient’s social health journey in addition to their clinical health, gaps in care can be mitigated.
The CCN began in 2016 in Nevada with referrals to community resources within the hospital, using an existing technology. In late 2017, the CCN began making referrals to a dozen external community organizations in Santa Cruz, California, and saw significant benefits of bringing social workers and community program leaders together to network and understand the resources available.
Now, the CCN model has expanded to include more community-based organizations (CBOs), other stakeholders, and enhanced mechanisms for sustainability to rightly center health in the communities themselves.
How it works
At the heart of all CCN partnerships are four central tenets:
- A neutral community convener, which functions as the facilitator to bring together local community provider organizations, establish governance, manage network funding, and advocate and align the CCN with local initiatives.
- A robust 2-1-1 information system to provide resources and referrals to health, human, and social service organizations in multiple languages.
- A collaborative network of CBOs in order to strengthen linkages to support services by creating further access points for those seeking help.
- A technology platform that allows for effective referrals and coordination of care.
With these components, the subsequent community network promotes a no wrong door approach, enabling greater access to and accountability for needed nonclinical services. The CCN also shifts power from large systems to community partners through shared governance.
A 'community bank'
The CCN model includes an innovative “community bank” concept, which ultimately creates a sustainable funding mechanism for public-private partnership. Funding Partners will contribute to the community bank and share in community infrastructure costs.
