3 Strategies for Taking a Community-Centered Approach to Care Coordination


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At Healthify, we believe that health is a human right, and that health disparities are largely influenced by socioeconomic factors such as access to housing, food, education, and employment. These factors are commonly known as the social determinants of health.

Why take a community-centered approach to care coordination? 

As our team learns more about communities across the nation, one thing is certain: each community has a complex ecosystem of individuals, organizations, policies, and programs. While each of these entities independently addresses the social determinants of health, we recognized the need to join these forces into one network aligned around shared goals. To us, a network is a collection of healthcare, educational, governmental, and community-based organizations that collaborates and coordinates to achieve improved health outcomes within their community.

In our mission to build a world where no one’s health is hindered by their need, we fundamentally value taking a community-centered approach to building networks by involving individuals at every level of the community ecosystem. It’s critical that we build upon the resilience, partnership, and dedication that is already evident in each community.

Over the past year, Healthify has partnered with the Howard County Health Department in Howard County, Maryland to build a network of 27 community organizations. Our program, CAREAPP, aims to connect individuals in the county to community resources, improve health outcomes, and reduce healthcare costs. The CAREAPP project rests on the technology built by Healthify, including robust data analytics and a platform that enables care teams across agencies to “close the loop” on social service referrals.

As we reflect on the challenges, successes, and teamwork over the past year, here are some tried and true strategies for taking an impactful community-centered approach to building a network:

1) Identify and empower community leaders

When introducing a transformational change to a community, it’s imperative to identify collaborative and innovative leaders. At the start of the CAREAPP project, the Howard County Health Department formed a Steering Committee, a group composed of leaders from organizations in our network, ranging from small transportation organizations to large hospitals.

As advocates for the community, they provide strategic and tactical guidance on the technology and implementation of the program. We are able to empower them by giving them a voice in the direction of the program, and their feedback and action were essential for us when we faced barriers or setbacks.

2) Build trustworthy relationships

Community organizations vary in size, offerings, funding, and structure, and it’s important to ensure that each individual and each organization feel as if they are part of a united team. In Howard County, we hosted a series of collaborative workshops, focus groups, and networking sessions to create opportunities for organizations to work together to discuss challenges, ideas, and best practices. Through this, we’ve seen existing partnerships grow stronger and new relationships form. Trust is a key ingredient for progress, perseverance, and the sustainability of these relationships, and ultimately, the network.

3) Listen to the frontline staff

Frontline workers are the ones that matter most in this process. These are the social workers, nurses, community health workers, and care teams. At each stage of CAREAPP’s implementation and through each version of our product, we measured and evaluated the value of our solution. The secret sauce here is the ability to empathize, improve, and adapt the technology and its implementation to frontline workers’ needs.

Pro tip: Our care teams love getting involved in this process, giving us feedback, and contributing to an evolving product!

At Healthify, we value systems-thinking and empathy, and we merge these two values in our community-centered approach to addressing the social determinants of health. By empowering community leaders, building networks based on trust, and iterating consistently, we help communities build an end-to-end solution that fits their needs best.

Are you looking to engage and improve care coordination with community partners in your area?  Schedule a demo. We'd love to help you build out your community partner network. 

Topics: social determinants of health coordinated care

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