Bridging the Sectors: A Compendium of Resources

Integrating to Improve Health: Partnership Models between Community-Based and Health Care Organizations

Nonprofit Finance Fund, 2018

This resource outlines common partnership elements and establishes a framework to describe integration between community-based and health care organizations.

Building the Value Case for Complex Care

Camden Coalition of Healthcare Providers and the National Center for Complex Health & Social Needs, 2021

This toolkit is designed to help organizations gain the support of key stakeholders within the organization, as well as outside funders, partners and payers, in making the business or value case for complex care. Content includes how to adjust the value case in times of crisis and ways to champion efforts in various environments.

Building Effective Health System-Community Partnerships: Lessons from the Field

Center for Health Care Strategies, 2021

This brief shares considerations for health care organizations and government entities working to build effective partnerships with the individuals and communities they serve and better address their health and social needs. It draws from the experiences of two sites: Hennepin Healthcare in Minneapolis and the Los Angeles Department of Health Services Whole-Person Care Program.

Ensuring Access in Vulnerable Communities Community Conversations Toolkit

American Hospital Association, 2017

This toolkit provides ways in which hospitals and health systems can broadly engage their communities using community conversations events, social media and the community health assessment. It also outlines how to focus engagement on specific stakeholders, including patients, boards and clinicians.

Lessons Learned from Partnerships Between Networks of Community-Based Organizations and Healthcare Organizations

Nonprofit Finance Fund, 2021

This report from the Advancing Resilience and Community Health (ARCH) initiative highlights themes and lessons learned that can inform new approaches to advancing community health. Through ARCH, Nonprofit Finance Fund partnered with three networks — EngageWell IPA, Metropolitan Alliance of Connected Communities, and Thomas Jefferson Area Coalition for the Homeless — to explore what it takes for CBO networks to come together around a shared vision for partnering with health care.

The Partnership for Public Health

American Hospital Association, 2020

This webpage offers a suite of tools and resources that showcase leading strategies for active collaboration across the public health field. These resources were developed by engaging health care leaders across the U.S. as part of the Partnership for Public Health project, a joint effort between the Center for State, Tribal, Local and Territorial Support (CSTLTS) within the Centers for Disease Control and Prevention, American Hospital Association and the National Association of County and City Health Officials.

Advancing Health Equity: PATH Addendum

Nonprofit Finance Fund, 2020

Effective partnership between community-based and health care organizations includes actively working to eliminate obstacles to health and ensuring that everyone has a fair and just opportunity to be as healthy as possible. This addendum to the Partnership Assessment Tool for Health (PATH) helps elevate the pivotal role that such partnerships play in contributing to equitable health outcomes in communities.

Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration

Public Health Leadership Forum and Health Care Transformation Task Force, 2018

This report provides a framework to facilitate collaborative working relationships between the public health and health care sectors. The framework includes tactics and actionable strategies to support several elements of collaboration: governance structure, financing plan, cross-sector prevention models, data-sharing strategy, and performance measurement and evaluation.

A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health

American Hospital Association, 2017

This playbook offers effective methods, tools and strategies for creating new partnerships and sustaining successful existing ones. The playbook incorporates lessons learned from the Learning in Collaborative Communities cohort, 10 communities across the U.S. with strong, successful hospital- community partnerships.

Partnership Assessment Tool for Health

Nonprofit Finance Fund, 2017

Designed for community-based organizations and health care organizations already engaged in partnership, the Partnership Assessment Tool for Health, or PATH, provides a format to understand progress toward benchmarks characteristic of effective partnerships, identify areas for further development and guide strategic conversation. The tool is designed to help partnering organizations work together more effectively and maximize their impact.

Capturing Patient and Staff Experiences to Assess Complex Care Program Effectiveness

Center for Health Care Strategies, 2022

This brief shares insights from three Advancing Integrated Models pilot sites — Center for the Urban Child and Healthy Family at Boston Medical Center, Hill Country Community Clinic in California, and Denver Health — as part of a Robert Wood Johnson Foundation national initiative. These health care organizations tested a practical set of patient- and staff-reported measures to assess key aspects of complex care delivery.

One-Stop Shop for Health Care and Community Partnerships

HealthBegins, 2021

This guide offers tools and vetted information on how to initiate, structure and fairly finance partnerships between health care organizations and community-based social service providers. Content is refreshed regularly.

Readiness Assessment Tool

Aging and Disability Business Institute, 2020

This tool guides a community-based organization through the process of successfully preparing for, securing and maintaining partnerships with the health care sector, by assessing the organization’s current readiness and also providing a framework and resources for navigating the process successfully. (Must log in or create an account for free access to this tool.)

Nonprofit Readiness for Health Partnership

Nonprofit Finance Fund, 2018

This tool assesses a community-based organization’s readiness to engage in partnership with health care organizations to deliver outcomes related to social determinants of health. It helps organizations review key capacities likely required for successful outcomes-oriented partnerships, to identify the organization’s strengths and weaknesses and to determine what capacity building and investment the organization may require before engaging in outcomes-oriented partnership arrangements. The tool is designed for self-assessment and internal use and not intended to evaluate potential partners.

Hospital Guide to Reducing Medicaid Readmissions Toolbox

Agency for Healthcare Research and Quality, 2017

This package of tools accompanies the Hospital Guide to Reducing Medicaid Readmissions, which offers in-depth information about the unique factors driving Medicaid readmissions and a step-by step process for designing a locally relevant portfolio of strategies and collaborating with cross- setting partners to reduce Medicaid readmissions. Some of the tools are adaptations of best-practice approaches to make them more relevant to the Medicaid population; other tools are newly developed.

Complex Care Startup Toolkit

National Center for Complex Health & Social Needs, 2022

The Complex Care Startup Toolkit is a practical collection of guides, templates and other tools for new and developing complex care programs, regardless of setting, population or geography. With examples from programs and organizations across the U.S., the toolkit covers program design, program operations, data and process improvement, team and leadership development, community mapping and collaboration, and communication.

Community-Based Care Coordination – A Comprehensive Development Toolkit

Stratis Health, 2020

This resource provides a variety of tools for use at different stages in the development of a community- based care coordination program, including how to begin a program. Tools focus on people, functions, policy and processes to achieve success in the community-based care coordination environment.

Care Coordination Toolkit

Centers for Medicare & Medicaid Services, 2019

This toolkit highlights innovative care coordination strategies that Medicare accountable care organizations use to collaborate with beneficiaries, clinicians and post-acute care partners to ensure high-quality, effective care is provided at the right time and in the right setting.

Community-Clinical Linkages for the Prevention and Control of Chronic Diseases

Centers for Disease Control and Prevention, 2016

This guide outlines key strategies for public health practitioners implementing community-clinical linkages that focus on adults age 18 and older, with the rationale, key considerations and potential action steps for each particular strategy. It also includes resources for public health practitioners to use when implementing a strategy and shares examples of community-clinical linkages.

Investing in Social Services as a Core Strategy for Health Care Organizations: Developing the Business Case

KPMG Government Institute, 2018

This guidebook is geared toward all payer and provider organizations that currently bear some form of risk for managing total costs of care for a distinct population. Though focused mainly on organizations that are responsible for managing high-need, high-cost populations, this guide offers steps and practical approaches for any organization (payer or provider) that either currently bears risk or is in the process of moving to risk-based remuneration models for a covered population.

Community Paramedicine Business Case Assessment Tool

Center for Health Care Strategies, 2016

This tool forecasts costs and savings under different implementation and expansion scenarios, and identifies cost and savings drivers — such as patient volume, health service costs and operating costs — and how these drivers affect financial performance.

ROI Calculator for Partnerships to Address the Social Determinants of Health

The Commonwealth Fund, 2020

This tool is designed to assist community-based organizations and their health care partners in exploring, structuring and planning sustainable financial arrangements to fund social services for people with complex needs. Organizations can use the return on investment calculator to compare the financial returns and risks arrangements between cross-sectional partnerships under a selection of payments models.

Health Care and Community-Based Organization Partnership: What Does It Cost?

Nonprofit Finance Fund, 2018

This resource guides partnerships in estimating costs to help align goals, prioritize decisions, communicate with stakeholders and advocate for funding.

Collaboration Toolkit: Creating an MOU

Colorado Nonprofit Association, 2013

This toolkit explains what a memorandum of understanding is, what it should include and the process for creating or revising an MOU, and provides additional resources and references.

Community Health Assessment Toolkit

American Hospital Association, 2023

This toolkit offers a nine-step pathway for conducting a community health assessment and developing implementation strategies.

Applying Research Principles to the Community Health Needs Assessment Process

American Hospital Association, 2016

This guide identifies tools and research principles to support community health needs assessments, describes patient- and community-centered practices to integrate into data collection during the CHNA process, and provides direction for identifying evidence-based resources to inform CHNA implementation strategies.

Geographic Data Sources for Assessing Health-Related Social Risk Factors

Center for Health Care Strategies, 2020

This resource summarizes publicly available data sources that can be used to further understand community-level, health-related social risk factors to better understand needs of potential high-risk populations. It was produced as part of a national initiative that brings together leading innovators in improving care for low-income individuals with complex medical and social needs.

Population Health Toolkit

National Rural Health Resource Center, 2019

In cooperation with the Federal Office of Rural Health Policy, this toolkit provides visualizations of data from multiple sources that answer questions that rural hospitals and communities have about the health of their communities. Users can explore their data further by downloading the information to create their own analysis and graphs.

Patient and Family Advisory Councils Blueprint

American Hospital Association, 2022

This resource shares learnings and insights from a group of patient and family engagement leaders convened by the AHA. It offers guidance to help organizations build and maintain a high-performing patient and family advisory council, highlighting examples and key takeaways from the COVID-19 pandemic and linking to additional tools.

Lessons on Consumer Engagement from Amplify

Camden Coalition of Healthcare Providers, 2022

This brief shares lessons of authentic consumer partnerships, highlighting opportunities to build trust, foster equity and inclusion, support community health and well-being, and improve health outcomes. It is designed to help organizations establish mutually beneficial partnerships with community members and individuals with lived experience.

Change Package: Person-Centered Engagement at the Organizational Level

Community Catalyst/Center for Consumer Engagement in Health Innovation, 2020

This toolkit is for leaders and staff at organizations across the health care spectrum — hospitals, large medical practices, health clinics, health plans, accountable care organizations and more — to aid in developing meaningful person-centered engagement structures at the organizational level. It incorporates lessons from three case studies and includes tools and strategies for planning, implementing and scaling person-centered engagement structures.

Screening for Social Needs: Guiding Care Teams to Engage Patients

American Hospital Association, 2019

This tool from the AHA’s Value Initiative is designed to help hospitals and health systems facilitate sensitive conversations with patients about nonmedical needs that may be a barrier to good health. It includes strategic considerations for implementing a screening program, tips for tailoring screenings to hospitals’ unique communities, case examples and a list of national organizations that can help connect patients with local resources.

Better Care Playbook: Building Shared Outcomes with Community-Based Organizations

Center for Health Care Strategies, 2019

The “Playbook” series of resources was developed in partnership with the Camden Coalition of Healthcare Providers to share practical lessons and actionable guides in serving complex populations. This resource provides guidance to help health care organizations and community-based organizations build relationships that draw on each other’s strengths, put patients first and support ecosystem development in local communities.

Engaging Patients and Community Members in Trauma-Informed Care Implementation Planning

Center for Health Care Strategies, 2019

This fact sheet outlines considerations to guide health care organizations in meaningfully engaging patients and community members in designing and implementing a trauma-informed approach to care.

High-Need, High-Cost Patient Personas

The Commonwealth Fund, 2019

This toolkit includes a series of “personas” for different types of individuals with complex health and social needs, as well as their caregivers. The personas — which include people who are older than 65 with functional limitations, those who have an advancing illness, those who have three or more chronic conditions, and others — help depict the experiences, motivations and goals of a group of patients, as well as the barriers they face.

Rural Community Health Toolkit

Rural Health Information Hub, 2017-2024

This toolkit provides rural communities with the information, resources and materials needed to develop a community health program. Each of the toolkit’s six modules contains information that communities can apply to develop a rural health program, regardless of the specific health topic the program addresses.