The Community Access to Coordinated Healthcare (CATCH) Network is a service delivery system made up of six local health departments and one Community Action Agency in Southeast Nebraska. It seeks to improve care coordination between primary care clinics and local health departments across 30 rural counties in Nebraska through building comprehensive screening capacity that meets the clinical, behavioral, and social needs of high-risk chronic care patients with heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, and depression.
What has been an early accomplishment or win of your participation in the network grant?
This implementation grant has really helped us build a stronger partnership. We are trying to improve care coordination between local health departments and primary care clinics, and eventually other community partners. Since our planning grant, we were able to add a new health department and recruit three very small clinics that are located in fairly isolated areas near the South Dakota-Nebraska border. These three small clinics were not screening for the social determinants of health, but we feel by bringing in these new clinics, we have an opportunity to address some of these issues that they were not previously looked at in an integrated way.
What advice or wisdom would you give them based on your experience so far?
It is really important to build leadership and trust among network partners. That is easy to say and very hard to do, and it has been made even more difficult with the COVID crisis. Obviously, health departments are the incident command centers at the local level, and primary care clinics are right in the middle of it as well. Even though it has been more challenging to do care coordination, we feel we are still building trust among our members because they’re working together in some cases more closely because of the COVID crisis. Local health departments are relying on primary care clinics to do testing and inform them of cases. So even though we have not been able to focus and put as much emphasis on care coordination, we are still building the trust and hopefully developing the leadership that we need to move forward.
We think that bringing people together and continually building trust, and developing leaders throughout your network is very, very critical. I know, based on experience, that over a three-year project, there will be some turnover. So, if we rely on just a few people and lose a couple of them, it makes it very difficult to maintain momentum.
Can you share an example that illustrates the value of engaging your network?
One of the things that we found is that most clinics, to our surprise, were already screening for depression and some mental health. It was brought to our attention how this screening identified two people — a high school student and a farmer actually who both had some fairly serious depression issues that probably would not have been caught as soon as they were without this screening.
In our project, we want to screen for clinical issues, especially heart disease, hypertension, diabetes, and depression, but we also want to screen for risk factors, such as tobacco use, obesity, as well as the social determinants of health. With COVID, the screening is happening a little more sporadically, but hopefully, we are going to reach an endpoint on COVID and will become more consistent, with the idea that once you are doing this screening, then the local health department can help address those personal risk factors and also serve as a link between the clinic and other community-based organizations for the social determinants of health. Although local health departments are not going to resolve those social determinants necessarily, we think that they can play a role, especially when small rural clinics do not have the capacity or the linkages to really follow up.
How will your organization or project emerge stronger from the pandemic?
COVID has been an enabler, and it has also created some disadvantages. I think it has helped build stronger partnerships between primary care clinics and local health departments, but it has clearly slowed care coordination efforts as we had envisioned when we wrote this grant.
One of the lessons of COVID is that we have to double down on chronic disease care coordination as we have found — to no one surprise in public health — that health disparities related to the social determinants of health are major issues. We have to address the health inequities and just do better chronic care coordination in general. In Preventing Chronic Diseases, the CDC put out a very nice article where they talked about how important it is to address these chronic care issues because we know that people are at greater risk with COVID-19 if they have a chronic disease. I think it is going to become even more important to double down and really emphasize getting people healthier and addressing the social determinants of health. So, we think our project fits very well in terms of where we are going and what we are trying to do.