We help health care organizations achieve their goals for team development, clinical care, and community impact.  

Today’s health care organizations are being pressed to define and demonstrate their value in return for funding. We help health care organizations meet this value challenge by optimizing care models in response to community needs.  We provide these supports for community health centers, community behavioral health agencies, free and charitable clinics, hospitals and health systems, medical practices, pharmacy programs, and more. We can deliver support to a single organization, or to groups of organizations through collaborative initiatives of associations, foundations, and federal grant initiatives. Learn more below.

Community health needs assessment is a requirement for some health care organizations.  Regardless of the requirement, community needs assessment can provide vital insight into population health patterns that can affect the future of the organization.  We help health care organizations conduct community health needs assessments that are strategically focused and efficiently implemented.  We can help you:

  • Focus assessment objectives
  • Design assessment methods
  • Develop community health indicators
  • Obtain community insights
  • Inventory community assets
  • Produce assessment reports, data portals and visualizations
  • Educate stakeholders about assessment results.

For clinical programs and organizations, the key to sustainability is to define and communicate value in ways that matter to key stakeholders. By applying a systematic Community Value Analysis, a program or organization can define its value for key partners and funders, and use the results to drive improvement and make the case for funding.  CHS offers training and technical assistance to help organizations conduct Community Value Analysis using a five-step process:

  • Define Your Audience
  • Understand Audience Expectations
  • Define Your Value Story
  • Define and Produce Your Key Value Indicators
  • Produce and Deliver Your Value Reporting Products
View an outline of the Community Health Center Value Model we developed in collaboration with the Virginia Community Healthcare Association.

The patient-centered medical home (PCMH) is a model of care that is intended to optimize the patient experience within and beyond the primary care setting.  Community Health Solutions has substantial experience and an extensive toolkit for helping primary care practices build capacity for  PCMH.  For practices seeking to achieve or sustain NCQA Patient-Centered Medical Home (PCMH) Recognition, we have specially trained staff and a detailed toolkit designed to streamline the capacity building process.   We also support practices that aim to develop specific aspects of the PCMH model without necessarily seeking formal recognition.  We are especially adept at helping safety net providers navigate their way through PCMH development.  We help primary care practices:

  • Assess needs and fefine objectives for PCMH development;
  • Design strategies for building PCMH capabilities;
  • Develop capacity for implementing the PCMH model;
  • Optimize execution through focused problem solving and innovation;
  • Demonstrate value through strategic measurement and reporting on PCMH impact and outcomes.

Chronic care management is designed to optimize the care of patients who have or are at significant risk for chronic conditions.  The prevalence of chronic conditions has been increasing due to the aging of the population and rising levels of lifestyle-related risk factors.   Projecting these trends forward, the growing burden of disease and costs could be crippling.  Consequently, chronic care improvement is a high priority for population health management.  Community Health Solutions can help you:

  • Assess needs and define objectives for chronic care improvement;
  • Design strategies for building chronic care capabilities;
  • Develop capacity for implementing chronic care improvement;
  • Optimize execution through focused problem solving and innovation; and
  • Demonstrate value through strategic measurement and reporting on chronic care impact and outcomes.

Integrated primary care models provide systematic coordination of primary care and other services such as behavioral health care and oral health care.  A growing body of research shows that integrating primary care with other services can produce positive outcomes for people with multiple healthcare needs.  Integrated care models can be designed in a variety of ways depending on population health needs and the capacity of local health care organizations.  Community Health Solutions can help you:

  • Assess needs and define objectives for integrated care;
  • Design an integrated care model that meets defined needs;
  • Develop organizational capacity for integrated care;
  • Optimize execution through focus problem solving and innovation; and
  • Demonstrate value through strategic measurement and reporting on integrated care management and outcomes.

Care transitions occur when a patient moves from one health care provider or setting to another, or from a health care provider to home.  Effective care transitions are important for optimizing patient health and for avoiding unnecessary utilization of hospital services and related services.  Community Health Solutions works at the community level to support the development of community-based care transition models. We can help you:

  • Assess needs and define objectives for optimizing care transition for specific groups of at-risk patients;
  • Design care transition models that meet defined needs utilizing evidence-based practices and community partnerships;
  • Develop organizational capacity for implementing care transitions;
  • Optimize execution through focused problem solving and innovation; and
  • Demonstrate value through strategic measurement and reporting on care transitions impact and outcomes.

Quality has always been important in health care, but QI takes on new meaning in an environment of population health management.   Today’s payers are highly focused on quality, outcomes, and cost measures as they relate to their sponsored populations.  Evidence of this trend can be seen in the expanding array of pay-for-performance models and reporting requirements for patient-centered medical home recognition and other types of credentialing programs.   The challenge for health care organizations is to develop a quality management program that has authentic clinical value to the organization while also meeting the requirements of external funders and oversight agencies.  We can help you:

  • Assess needs and define objectives for clinical quality;
  • Design an efficient portfolio of quality measures;
  • Develop organizational capacity for quality improvement and quality measurement;
  • Optimize execution of quality management including data development, analytics, reporting, review, and action; and
  • Demonstrate value through strategic quality measurement and reporting.

Clinical-community partnerships can be essential for optimizing care for patients who need support in the home and community setting.  We help health care organizations develop effective strategies to:

  • Assess patients’ social risk factor and community support needs
  • Incorporate home and community support goals into care plans
  • Identify community resources and create referral connections
  • Track and optimize patient utilization of community support services
  • Evaluate impacts of clinical-community connections on patient experience and outcomes.

Population health management requires new capabilities for improving health and health care for defined populations.  Essentially, health care organizations must be able to demonstrate value by delivering effective care models to define groups of patients based on assessed levels of risk.  We can help you:

  • Assess needs and define objectives for population health management;
  • Design strategies for enhancing population health management;
  • Develop capacity for implementing population health management for specific patient populations;
  • Optimize execution through focused problem solving and innovation; and
  • Demonstrate value through strategic measurement and reporting on population health management impact and outcomes.
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