Rebounding from COVID-19: How whole-person health care can guide the way

America’s economic and racial inequality, thin social safety nets and fragmented health care system are putting the most disadvantaged people at the greatest risk from COVID-19. Yet, in the midst of this crisis, there are inspiring examples of organizations that are transforming health care through trust-based relationships and community partnerships that provide whole-person care for people’s physical, economic and social needs.

The pioneering research of forest ecologist Dr. Suzanne Simard offers a metaphor for what these health care organizations do. Trees, it turns out, are in constant relationship with each other via large underground networks through which they communicate and share essential nutrients. The large hub, or “mother,” trees  anchor the health of the forest, supporting other trees’ growth and their quick recovery after stress and disease.

Right now, some health care groups are acting like hub trees to enable resilient community health. Structured as Accountable Care Organizations (ACOs) or Accountable Communities of Health (ACH’s), these organizations offer an alternative to the dominant system of health care, which depends on maximizing the volume of medical services. Instead, ACOs and ACHs aim to improve their patients’ overall health outcomes by going beyond clinical care to address the social and economic life influences that determine health and wellbeing. Like forest hub trees, they form relationships with patients and other community organizations, connecting diverse parts of the local health care ecosystem to coordinate care for patients’ diverse needs. 

Whole person care relies on empathetic relationships with patients to understand a wide range of  factors that influence people’s lives. The Camden Coalition in Camden, New Jersey is an ACO-like partnership that is well known nationally for using integrated care to prioritize health services for people with complex health problems. The coalition’s goal is to build authentic healing relationships with people to help them realize their highest level of health and wellbeing.

To do this, a frontline team of “Patient Navigators” functions like the roots of a hub tree to support patients in the health care network. Responding to the pandemic crisis, Patient Navigators expanded Camden’s social determinants of health screening to all members being tested for COVID-19. Navigators survey people to find out how the Camden Coalition can best offer whole person care by asking how they are doing physically and mentally, inquiring as to their necessities (food, housing, utilities, social connection and personal safety) and whether they have access to the necessary resources.

The Navigator then connects the member to community organizations that provide housing, food programs, legal help and other services. The coalition makes daily calls to those partners to get up-to-date information on their operations and capacity. The patient’s information is sent to Camden’s Health Information Exchange, which centralizes real-time patient data from a variety of sources and flags patients for follow-up care. The coalition is also taking steps to ensure equitable access to care, for instance providing iPads to a local homeless shelter for telehealth appointments and working with other municipal and state agencies to overcome racial health inequities. Its partners include Camden’s Police Department, which is regarded as a national model for progressive policing.

HealthierHere, an ACH in the Seattle region, is playing a similar hub tree role on the other side of the country. In 2018 HealthierHere launched an effort to improve health equity and outcomes via a Consumer Voice Listening Project that engaged 34 community organizations and nearly 3,000 community respondents from 40 surrounding communities. Through this initiative, HealthierHere developed a solid grasp of community needs and cultivated an extensive network of relationships with partner organizations that undergird its COVID-19 hub activities in the local and state health care ecosystem.

As the COVID-19 crisis accelerated, HealthierHere quickly assembled a Resource Hub to assist its clinical and community partners to adapt their practices and connect with local resources. It launched an early telehealth initiative and then helped to create a statewide infrastructure for future telehealth care. HealthierHere also accelerated the implementation of a Community Information Exchange, a network of cross-sector partners who coordinate to ensure that individuals have better access to the care and the social support they need. The CIE will provide real-time online information about the capacity of local agencies and non-profit groups to support people’s needs for social services like food and housing.

The multi-stakeholder, accountability-focused design of whole-person health care organizations enables them to meet people’s social and medical needs in a holistic way during COVID-19, while simultaneously improving the health and resilience of the larger regional and state health care ecosystem. As communities of color are devastated by COVID-19, these health care models could offer a model for the future of equitable, trust-based community health and health care. 

Gary Hirsch, SM, is a consultant who specializes in applying System Dynamics and Systems Thinking in the development and program planning for health care organizations as well as educational and news media institutions. He is the co-author of three books and numerous journal articles. 

Kate Isaacs, Ph.D, is a research scientist at the MIT Sloan School of Management and an executive fellow at the Center for Higher Ambition Leadership. She is a skilled advisor to senior leaders on innovation-focused stakeholder partnerships that generate economic and social value. She has written for The Hill, the Harvard Business Review, Chief Executive and the Academy of Management.