Accelerate your Community’s Transformation to Whole-Person Care

“Where people combine their talents and efforts to design organized services for patients and local communities, extraordinary change can result.”

Atul GwandeCowboys and Pit Crews

Introducing
the Health Commons Project

Situation

Today, health and social service providers in the community work on “care islands” – – while they appear close in proximity, communication and reporting barriers make it difficult for providers to track and coordinate care as an integrated team. Communities with fragmented systems of care produce relatively low achievement in population health and well-being.

To improve population health and well-being, communities are breaking down care silos to create connected and sustainable systems for delivery of whole-person care – – systems where providers work together to direct their specialized capabilities towards common goals for individuals and populations.

To create these fully integrated systems of care, communities are:

  1. Aligning people, processes, and incentives across organizations and sectors: medical, dental, behavioral, social service, first responders, housing, transportation, legal, education, etc.
  2. Connecting organizations and sectors to a common technology infrastructure that enables information sharing and dissemination of best practices

We are group of PNW communities, provider organizations, and technologists dedicated to creating connected and sustainable systems for delivery of whole-person care. We call these new systems Natural Communities of Care.

A Natural Community of Care is a fully integrated system of care where health and social service providers work together to ensure there is “No Wrong Door” for people to access the care and services they need. A Natural Community of Care is designed to improve the population health and well-being of individuals and populations.

A Natural Community of Care is powered by a technology platform, called the Health Commons Network (Commons). The Commons is a communication network that digitally connects health and social service agencies in a community. Where agencies are connected to the Commons:

  • Providers can share the information needed to coordinate and track care as an integrated team
  • Organizations can disseminate strategies, workflows, and best practices that improve population health and well-being.

Community Pioneers Committed to the Health Commons Project

Olympic Community of Health Commons Project

Clallam Commons Pilot: Addressing the Opioid Use Public Health Crisis, Primary Care / Behavioral Health Integration & Community-Based Care Coordination

Greater Columbia ACH Commons Project

Kittitas Commons Pilot: Improving Transitional Care & Community-Based Care Coordination

South King Health Commons Project

South King Commons Pilot: Improving Diversion Care, Transitional Care & Community-Based Care Coordination

How to set up your
Natural Community of Care


When you join the Health Commons Project, you are assigned a Commons Project Team. The team works with your organization at the “grassroots” level to create and sustain a Natural Community of Care.

The Commons Project Team follows IHI’s Pathways to Population Health Framework to ensure that your voice and goals are fully understood and there is a plan for success.

The Commons Project Team guides you through the following steps to create a Natural Community of Care and connect to the Health Commons Network (Commons).

Phase I

LEARN

  1. Identify key stakeholders within your organization and across organizations / sectors
  2. Work at the “grassroots” level to ensure your voice and goals are fully understood
  3. Understand the current gaps in care affecting community members and patients
  4. Define a shared vision of your community goals, success measures, and team commitments
  5. Prioritize which community services you would like to connect to the Health Commons Network
Phase II

ACT

  1. Design workflows to support connectivity between agencies
  2. Match needs / wants of agencies to best-in-class innovations
  3. Complete pilot test of new workflows / technologies, prove utility, and connect to the Heath Commons Network
  4. Roll out the Health Commons Network to Natural Community of Care stakeholders until services are fully integrated
Phase III

IMPROVE

  1. Establish benchmark and target measures
  2. Complete “Plan-Do-Study-Act” (PDSA) cycles until target measures are reached
  3. Measure and sustain Health Commons Network in partnership with regional Accountable Communities of Health and Managed Care Organizations

Connecting Natural
Communities of Care to
the Health Commons Network


The Health Commons Network (Commons) is a digital communication system that connects health and social service agencies in a community. Where agencies in a Natural Community of Care are connected to the Commons:

  • Providers can share the information needed to coordinate and track care as an integrated team
  • Organizations can disseminate strategies, workflows, and best practices that improve population health and well-being.

Before the Commons Network

After the Commons Network

The Commons supports a wide range of digital tools including Electronic Health Record, eReferral, Health Information Exchange, eConsult, Secure Chat, Digital Consent and Remote Monitoring.

The Commons is vendor agnostic. The Commons Project Team works with your organization to identify and implement best-in-class technology based on what is best for each pilot test / use case.

The Commons operates like a public utility. Partnering organizations in a Natural Community of Care develop a financial model to sustain the Commons. Each organization that connects to the Commons uses their voice to drive system improvements.

To learn more about joining the Health Commons Project, send us quick description of:

  • Your agency, services you offer, geography you cover and population you serve
  • Agencies you partner with and how you communicate with those agencies today
  • If you joined the Health Commons Project, what would success look like

For inquiries in Clallam, Jefferson, and Kitsap Counties (Olympic Region),
contact Celeste Schoenthaler at Celeste@olympicch.org

For inquiries in Clarkston, Ellensburg, Pullman, Tri-Cities, Walla Walla, and Yakima,
contact Carol Moser at cmoser@gcach.org

For inquiries in South King County,
contact Adam Davis at ADavis@pugetsoundfire.org.