Community Integrated Health Team: Exploration of Team Successes and Setbacks

Overview: This paper explores some common factors that lead to or create obstacles to the success of Community-Based Integrated Health Teams (CIHT). Important themes include team coordination and collaboration, challenges of limited internal and external resources such as stable housing and food security to the success of patient outcomes.Proposal text: Background/Rationale: Social workers are in high demand for jobs in integrated health settings that employ interprofessional teams for collaborative care (Zerden, Lombardi & Jones, 2019). The term, Community-Based Integrated Health Teams (CIHT), is meant to encompass an interprofessional team that manages the health of a patient through multiple systems of care. Empirical research on CIHTs has found mixed results. For example, a recently published study of Camden Coalition of Healthcare Providers, one of the nation’s first CIHTs, found no difference in hospital readmission rates between individuals participating in the program and a control group (Finkelstein, 2020). In contrast, evaluations of another nationally recognized CIHT, Community Care of North Carolina, found substantial reductions in inpatient utilization and annualized per-beneficiary net savings for Medicare and Medicaid of approximately $3 for every $1 invested (DuBard, 2018). The current study explores the common programmatic features and functions of multiple CIHTs that may support or limit success in improving the health of vulnerable patient populations—special focus included how teams adapt to the ongoing COVID-19 pandemic is given.

Methodology: Research assistants in law and social work conducted telephone interviews with health care clinicians, social workers, behavioral health providers, nurses, community health workers, pharmacists and other professionals who have been participating in CIHTs for at least 1 year. Twenty-nine people were interviewed, and seven organizations were represented in the sample. Thematic analysis (Braun & Clarke, 2006) was used to identify themes.

Results: Commonalities were discovered across responses regarding teams’ responses to meeting demands of medically complex patients with numerous mental, social and medical vulnerabilities. Emergent themes included: the team allows patients to define success; all teams are challenged by limited resources; team success requires excellent communication, coordination and collaboration; unstable housing and access to food interfere with the ability to keep patients focused on health as priority; and all teams were forced to innovate communications during the pandemic.

Conclusion: Our main finding is that success in community integrated health teams is made possible with excellent communication, adaptability, collaboration, and coordination. The need for continuous, clear and patient centered decision making implies that employment of a “high touch” focused personnel may be optimal for CIHTs. Patient success is often defined by the patient through the goal setting and care plan creation process. Teams commonly marked connection to resources as a sign of success. The inability to coordinate and collaborate due to systemic barriers entrenched in the U.S. healthcare system seem to be an overarching theme worthy of further research. Social workers trained in building rapport and working within interprofessional teams are poised to provide a critical communication bridge between team and patient and within the team. Recommendations for how to incorporate social work in CIHT to amplify the cause of health as a human right are provided.