Leveraging community resources to advance integrated care was a prominent theme in the recent North America Conference on Integrated Care – NACIC24 . We attended several sessions and workshops that centred on the development and implementation of innovative models that focused on connecting healthcare providers with local community organizations and social enterprises as well as social services to address the broad range of nonmedical needs – the Social Determinants of Health (SODH) – impacting patients’ health and well-being. By integrating these community and social resources, healthcare providers can better address the SODH such as food insecurity, housing, transportation and low-income – that play a crucial role in patient experiences and outcomes.
During these sessions, we explored various strategies that have been enacted in different contexts to address the SODH to improve care for socially disadvantaged populations. One workshop presented substantial advancements in a program to build collaborative pathways through social prescribing where a community link worker connected patients to community partners for nonmedical needs. They emphasized key ingredient for success such as building trust and respect between a willing coalition of community stakeholders primary care providers, champions within the healthcare sector who will promote the social prescribing referral pathway to peers, and well-resourced and documented programs and services that are available for the link worker to refer to. Other sessions discussed efforts to build a community of practice for SODH practitioners, capturing SODH using machine learning for an integrated care program, and building bridges to integrate health and social services in densely populated and diverse neighbourhoods in Toronto.
Some key strategies for leveraging community resources to strengthen integrated care emerged from these sessions. Building partnership with community organizations like food banks or transportation services to allow healthcare providers to effectively connect patients with services that directly address their unique nonmedical needs. Embedding community workers within healthcare teams to serve as liaison between patients, healthcare providers and community resources to help patients navigate the complex healthcare system. Enhancing the participation of healthcare providers in social prescribing programs like support groups or exercise programs which can reduce social isolation. Mapping local resources, enhancing collaboration between community organizations and leveraging digital platforms to facilitate referrals of patients to appropriate resources based on individual need. Investing in community outreach programs and patient engagement in research to educate the community on preventative and health promotion services and the availability of community resources to help patients understand how to access local support services.
These sessions also highlighted profound challenges to leveraging community resources to advance integrated care. Resource and funding constraints were frequently mentioned as community organizations are often under-resourced which limits their capacity to offer a broad range of services. Furthermore, community organizations often rely on grants and short-term funding, which is not reliable and impacts the sustainability of their services. There are also privacy and confidentiality issues where healthcare providers are reluctant to share patient information with community organizations.
In conclusion, NACIC 2024 series of sessions underscored the need to address challenges to the participation of community organizations in integrated care by securing sustainable funding and facilitating data sharing, as well as incorporating strategies to enhance community participation in integrated care. This will go a long way to creating a more cohesive and supportive healthcare system with integrated networks that extend beyond clinical settings to community resources that promote health equity and improve access, experiences and outcomes to socially disadvantaged communities.
