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Community-Centered Health Homes: Bridging Healthcare Services and Community Prevention

Tuesday, February 12, 2019   (0 Comments)
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Rea Pañares, Senior Advisor, Prevention Institute



Prevention Institute will be presenting at the Western Forum for Migrant and Community Health in Portland on February 21st.


Most healthcare organizations know that even the best treatment doesn’t stand a chance if the environments that patients return to after their doctor’s visit fundamentally undermine health. It can be frustrating and demoralizing when physicians’ work, and ultimately their patients’ wellbeing, is constantly undone by poor community conditions.


To address this issue, Prevention Institute, a national nonprofit that advances the practice of primary prevention, developed the Community-Centered Health Home (CCHH) model, which provides healthcare organizations with a framework to identify local community determinants of health and collaborate with partner organizations to improve community conditions.


The CCHH model has been piloted in 27 healthcare organizations (primarily safety-net clinics) in Louisiana, Florida, Alabama, Mississippi, North Carolina, and Texas to address issues as diverse as food insecurity, poor housing, workplace environmental hazards, and a lack of neighborhood parks and playgrounds. Last month, Prevention Institute published a 2nd edition of the original CCHH paper, which describes healthcare organizations’ experiences piloting the CCHH model and offers practical strategies for implementing it.


Health centers involved in CCHH demonstration projects have incorporated training about CCHH into new employee orientations, partnered with external organizations to take on the community determinants of health, and transformed their internal structures and systems to support CCHH implementation. For example:

  • People's Community Clinic in Austin, Texas uses its clinical expertise to advance health-affirming public policies. When community organizations needed a healthcare advocate to work with them on the issue of paid sick leave, the health center stepped up to the plate—the only healthcare organization involved in the campaign from start to finish. As a result of the clinic’s advocacy in collaboration with community partners, Austin became the first city in Texas to make paid sick leave a mandatory requirement for all non-government employers.i


  • For Highland Health Center in Gastonia, North Carolina, the CCHH model’s emphasis on authentic community partnerships helped build the health center’s connection to the surrounding community. The health center hired a local resident to serve as its coordinator, which has helped build trust and engage residents. As a result, residents have successfully advocated for park and infrastructure improvements, a priority of community residents ii


  • AccessHealth in Richmond, Texas educated staff about the clinic’s role in addressing community conditions that impact patient health. The clinic incorporated training about its CCHH initiative into the new employee orientation; hosted a training for the clinic’s billing clerks, front desk staff, and patient service representatives that explored the root causes of poor health; and increased staff awareness of social and community determinants of health by demonstrating how social and biological factors impact health and development.



What is CCHH?


A CCHH is a healthcare organization that acknowledges that factors outside the clinic walls affect patient health outcomes and actively participates in improving them. These factors include community conditions, like the availability of parks and open space, healthy food, affordable housing, clean air and water, and strong social networks.iii The CCHH model provides healthcare organizations a guide for how they can use their influence and expertise—as well create new partnerships—to make improvements within the communities they serve. This includes partnering with community residents and organizations to identify which health issues are a priority for community members and collaboratively developing solutions. Rather than presenting a model for healthcare organizations to engage in one-off projects to address community conditions, the CCHH model describes how healthcare organizations can institutionalize a community-centered approach to health by developing the culture, staff, systems, and initiatives needed to be effective in community work in an ongoing way. 


The CCHH model consists of a set of foundational and functional capacities (see Figure on right) to spark, inspire, and support healthcare organizations’ impact on shaping the health of the communities they serve. The functional capacities, which describe how a CCHH operates in the outside world, are Inquiry, Analysis, and Action. They describe how a CCHH can most effectively assess and identify community determinants of health, engage in collaborative planning and priority-setting with community partners, and contribute to improvements in the community conditions that shape health.



The foundational capacities describe how a healthcare organization needs to transform its internal organizational structure in order to be an effective CCHH. By addressing Leadership, Staffing, Knowledge & Skills, and Partnership a healthcare organization can integrate a community-centered approach into the fabric of the organization. In the CCHH paper, these capacities are laid out alongside example practices and included in a tool that healthcare organizations can use to assess their existing capacities to improve community conditions.


CCHH activities build upon a clinic’s existing efforts to provide enabling services that address the social needs of individual patients—such as food insecurity or poor housing—by working towards community-wide solutions (see chart). These strategies are developed and implemented alongside community partners and aimed at policy, system, and environmental change.




The Value of CCHH to Primary Care


Healthcare organizations participating in CCHH demonstration projects have begun to articulate how integrating CCHH capacities and practices into their work brings value to their organizations. Benefits described by some of the CCHH leadership include: enhanced achievement of the organization’s mission, increased staff pride, elevated visibility of the healthcare organization in the community, and increased trust by community members. As one health center leader explains, “I don’t have a marketing budget. Becoming a CCHH has elevated our status in the eyes of our community and enhanced the trust they have in us. Our volume has increased because people know who we are and that we are here for the long haul.”iv


Primary care providers recognize the impact of the social determinants of health on their patients and understand that having a strategy to address these community conditions can reduce illnesses and injuries, facilitate healing, and increase care team satisfaction and retention. Work and interest in healthcare–community partnerships to improve population health is growing and promises to intensify through increased efforts to transform the healthcare system. The CCHH model provides a unique contribution to this movement by offering a systematic approach to adding community centeredness to healthcare organizations’ daily mission of delivering high-quality services. As essential community assets, primary care organizations can use the CCHH model as their roadmap to inspire, strengthen, and lead healthcare in the uptake of broader strategies to promote community-level prevention and improve population-wide health and wellbeing for all. 





i Gandhi P. Guest Commentary: Let's address hunger and other community determinants of health. Modern Healthcare. http://www.modernhealthcare.com/article/20180310/NEWS/180319995. Published March 10, 2018. Accessed April 10, 2018.

ii Interview with Donyel Barber, Gaston Family Services, conducted on December 20, 2017.

iii Davis R, Rivera D, Parks Fujie L. Moving from Understanding to Action on Health Equity: Social Determinants of Health Frameworks and THRIVE. Oakland, CA: Prevention Institute; August 2015

iv Interview with Chandra Smiley, Community Health Northwest Florida, conducted on April 20, 2017.





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