Positively Impacting the Communities That We Serve

by Jamie Edwards, Senior Director
Community Care Behavioral Health Organization

In January 2021, Community Care Behavioral Health Organization (Community Care) embarked upon an  exciting challenge to build and launch a new initiative for behavioral health—Community Based Care Management. The goals of the program are to improve behavioral health outcomes, strengthen partnerships with Community-Based Organizations (CBOs), encourage the use of preventive services, eliminate social determinants of health (SDoH) barriers, and reduce health care disparities.

In each of Community Care’s 11 contracts across the state, county-level officials identified the SDoH that impact local regions the most and developed partnerships with 25 CBOs. Areas of need that are assessed and improved include housing and homelessness, food security, utilities, clothing, employment and financial strain, transportation, childcare, and health care access. CBOs are designated 501(c)(3) nonprofit organizations that are not existing behavioral health providers. Support for the initiative may extensively impact local communities in the mitigation of fundamental SDoH.

As part of the Community Based Care Management Program, Community Care hired 22 staff members to serve as community health workers and prenatal/postnatal care managers. The linkages and connections coming from this new initiative have been excellent. Pre-natal/Postnatal care managers have engaged with people on labor and delivery units, and community health workers have successfully conducted food and clothing drives for local communities.

Community Care will evaluate the impact of addressing SDoH and additional population health approaches. Enhancements have been made to our electronic medical record, PsychConsult, and ability to capture invoice and referral information to build data collection opportunities into the program. We are capturing members by initiative, adding a patient health questionnaire for postpartum depression screening, substance use screening, SDoH screening, and pregnancy-related screening. This has been an impactful initiative with great potential. Due to the positive internal cross-department collaboration, phenomenal partnership with our counties, and exciting new relationships with CBOs, we look forward to continuing this important work.

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