Coordination between healthcare, behavioral health and social service organizations to address social determinant needs and provide a continuum of care.
How ASSISTANCE Works in the Alliance Model:
When social needs are identified through screening, participants are connected to community services through a variety of approaches. In most instances, care management within each organization provides information, resources or direct links to social services. Based on the screening outcomes and the appropriate level of care need to address barriers, participants are asked if they would like the additional support of a community health worker (CHW).
In each community there is a CHW team who works collaboratively with all Alliance organizations, or those organizations screening SelectHealth Medicaid members for social determinants of health. The CHWs are a mobile unit who act as an extension of care management providing motivational interviewing, home visits, and self-management goal setting that empowers participants to address barriers to overall wellness.
Multi-agency teams are convening weekly on shared cases and remarkable progress has resulted from cooperative efforts to engage high-risk members through a full continuum of care. Often organizations are working with the same person, and these coordination meetings provide insight into other aspects of the participant’s care and opportunity to work collaboratively.