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Lauran Hardin, MSN, RN-BC, CNL, FNAP, is the Senior Advisor, Partnerships and Technical Assistance, for the National Center for Complex Health and Social Needs Lauran Hardinand senior director at the Camden Coalition. In this role she continues her past experience providing consulting, co-design and coaching in complex care transformation. Her special interests include the impact of trauma/loss on high frequency healthcare access and the economic potential of stabilizing complex patients through retraining/redesigning existing inter-professional resources in the healthcare system.

Hardin was previously the Director of a Complex Care Center serving hospitals, multiple providers and more than 1,500 high frequency/complex patients in the Mercy Health System. The Center’s model of complex care has resulted in better patient navigation and outcomes, including decreased emergency room visits, hospitalizations, and costs for diverse vulnerable populations. She received an Innovation Grant from Trinity Health, one of the largest multi-institutional Catholic health care delivery systems in the nation, and implemented aspects of the care model changing the system of care for complex patients in more than twenty Trinity Health ministries across six states.

Barilla: Hello, everyone, and welcome to Next Generation Community Health. I’m Dora Barilla with Providence St. Joseph Health, and I’m here on behalf of Stakeholder Health. Today, we’re joined by Lauren Hardin. We’ll be talking about social and clinical connections. Let’s get started by welcoming Lauren to the show.

Barilla: Thank you for joining us today, Lauren.

Hardin: Thank you, Dora. I’m really excited to talk with you today.

Barilla: No, I think it’s really exciting, especially in a time such as this, in terms of talking about just the great work that the National Center has been doing. I’m really curious if you can share with us a little bit about what the National Center for Complex Health and Social Need does, and your role there.

Hardin: Sure, be happy to. Two years ago, the Camden Coaliltion received funding from AARP, Atlantic Philanthropies, and Robert Wood Johnson to start a nation center for complex health and social needs. The reason for starting the National Center was they learned from their work in Camden how important it was to convene stakeholders to link people across communities and across organizations to begin to learn how we could improve care for vulnerable populations. And also to really move the field forward, for understanding complex health and social needs.

Hardin: I had the privilege of joining the team two years ago. My job is called Senior Advisor for Partnerships and Technical Assistant. I get to do three different, really interesting things. One part of what I do is partner with communities and systems for developing programs for complex patients. Another part is building partnerships with other organizations who are working to move this field forward. Then, a third part is really building out the core competencies and the structures in the field of complex care and partnership with others like IHI and CHCS and many others across the country.

Barilla: Wow. That’s really exciting. So, this is really looking at … this is transformational work for health systems in the country.

Hardin: It is.

Barilla: Wow.

Hardin: It’s a real privilege to have the window to be around at this point in the field and to help move it forward.

Barilla: Yeah. It looks like that this is you’re really looking at scaling this work that you’re doing. I know that you have a complex care map that you developed. Can you share with us a little bit about how it helps, what we call, either the high utilizers or friendly faces or … but individuals in your work?

Hardin: Sure. I’d be happy to. About 10 years ago, I was working in the Mercy Health System in Grand Rapids, Michigan, and I had the privilege and window to develop a model for complex patients. I was serving any of the folks accessing the healthcare system with high utilization or complex health and social needs. Parts of that model were very intentionally designed. The first component was really capturing a comprehensive patient story and really looking at, not only the medical, but the social, behavioral health, and system issues that were contributing to their instability. That story was so important for transforming care and for more people to understand.

Hardin: We had a collaborative group that was comprised of physicians, nurses, social workers, lawyers, pharmacists, all different disciplines, that were meeting weekly to really look at how we could improve care. One of the things the group really wanted to develop was a way to translate that story across the system. We were able to get technology built with an alert in the health record that popped up, and then people could link to this complex care map. We condensed that patient story into a one page, succinct version that helped providers across the system, whether they’re in primary care, the emergency room, across the hospital in radiology, that they could be armed with really helpful information so that they could personalize their care and understand the greater story and the social needs that were really important in that person’s life.

Barilla: Wow, that’s pretty impressive to be able to take … I mean, that’s a pretty significant level of complexity to really pull in, to make it so practical. That’s exciting to see that we’re taking the complexity and making use of it in just completely practical ways, Lauren.

Barilla: As you talk about that, you talk about just really your … as you identify a lot of the social needs and pulling that into the health care system, as we’ve been talking about what we, so call, social determinants of health or essential health services, we talk about housing, food and security, and social isolation, transportation. But maybe explain to our listeners why that’s so important in terms of healthcare and why healthcare and health systems should be engaged in these efforts.

Hardin: That’s a great question, and I think the people I worked with directly from the very beginning were such great teachers about why these factors are so important. I think back to a young man who was referred to my program, and he was in his 20’s and he had an address and a healthcare record and he had diabetes, and he had many, many ED visits and in-patient hospitalizations. When I met with him and when I talked to him about his story and really took the time to look across the community and really deeply understand what was happening for him, even though he had an address, he was couch surfing and he was too sick to work, so he didn’t have the funding to get stable housing, he didn’t have transportation, he had nowhere to safely store his medicines or to access healthy food. All of that was driving his high frequency access because there was no opportunity for him to stabilize his chronic disease without those foundational things that we kind of take for granted in our day-to-day life but are so important for people to have safety, security, and just the ability to heal.

Hardin: So, housing, transportation, access to healthy food, and even social isolation is so critical too. I took care of a gentleman who was in his 70’s and he had multiple visits with chest pain to the hospital. He had multiple cardiac workups and just coming back. When I really sat with him and learned his story, what was happening is he didn’t really have heart disease, his wife had died and he was lonely. He had heartache. I think when we start to look and pay attention as a standard to these components, we get deeper faster to the most important things for healing. There’s so much benefit for the person and their families, but also the healthy system. When you look at how high the costs are in healthcare, this is a real opportunity to improve our delivery and really improve the economy for our country.

Barilla: Yeah. I think that’s such a touching story, Lauren, and I think it could be replicated in so many health systems around the country, really looking at the whole person in addressing what’s really going on with people and what’s impacting them because we aren’t just physical beings, are we?

Hardin: No, and that’s why we all went into healthcare too-

Barilla: Yeah.

Hardin: Really is that healing and that relationship. A lot of people think, “Oh, that’s going to take so much time,” but it really doesn’t. It takes more time to not know the information and provide the wrong service over and over than it does to build a regular practice of standardly looking at these components and connecting with people about what’s most important to them.

Barilla: Yeah. It sounds like you’re, in a sense, building the toolbox for health systems in very different ways and adding a lot more interesting and diverse tools in there, and also, that includes partnerships.

Hardin: Yes.

Barilla: If you think about just partnerships in the future with health systems and community to address the social issues that are impacting health care utilization, what do you think those partnerships look like in the future?

Hardin: It’s a great question. What was, I think, some of the really exciting parts of the work, the deeper I got in understanding people’s stories who had high frequency access, it was really apparent that some of the root causes were only going to be solved by working collaboratively across the community. At first, I was based in a hospital, so when I first started learning about the need for housing, I thought, “Oh, I need to start a housing program and I need to go into this.” What I quickly learned was, there was all kinds of people across the community who already knew a lot about that, and I was going to be able to get a lot of farther if we partnered and I utilized the resources I had in my health system from a data perspective or a research perspective to partner across the community and utilize those resources to help the people who are really good at housing or really good at transportation, that we could partner and build a much stronger system of support for our community members.

Hardin: I think those partnerships are really exciting and it really starts to … it’s very motivating when you look at why we went into healthcare and what can happen when we collaborate. I’m seeing really exciting partnerships across the country with people that I work with. There’s partnerships happening in communities with police and fire and EMS and the mayor, people really coming together and seeing what is possible and the power of collaboration, and the efficiency and if we share and carry this work together, what we can get done and what kind of transformation we can create.

Barilla: Yeah, that really is far more exciting than just looking at your traditional X-ray and lab and your traditional partners, and really to expand it to the whole community. It’s a whole different ballgame and probably going to take a lot of different skillsets in our leaders as well in terms of what needs to happen in the future.

Barilla: My next question is really focused around, what is it that health systems and leaders and community based organizations can learn from individuals with complex health and social needs?

Hardin: I think that’s a great question. With some of the best lessons we’re bringing people to the table and design, so having people tell their stories so that as a greater community, we could understand the impact of some of the barriers, the desire for people to be healthy and whole, what really made a difference in their life, and then how we could look at our own systems through different lenses and really think about the person centered experience.

Hardin: Some of the barriers are not as apparent to us when we’re so used to navigating these complex systems. People with limited experience are much better at redesign, very good ideas about how things can change. I think the stories are really motivating to hear directly from the person about what is transformative and what the potential impact is, and what that means to people in their lives.

Barilla: Yeah, that makes a lot of sense, to really listen to the stories and what’s happening, and, I think a perfect way to begin to bridge the gaps between kind of that clinical and community health. But what else do you think we might need to help bridge some of those apparent gaps that are happening in our communities?

Hardin: I think intentionally developing structures where we come together around shared issues. I think there’s really great work happening in the transformation of, for example, community benefit from health systems and really looking at that as a partner in the community to really work deeply on transformation. I think the more we understand how to create a shared table, how to create collaborative outcomes that we celebrate collaboratively, we celebrate success together, rather than one organization taking credit, we share what resources we do have, so everybody has something to bring to the table.

Hardin: I was part of an event in a small community that their county has some of the worst health outcomes and biggest challenges and lack of affordable housing, provider shortages, minimal transportation. The community members sat together and they each took a few moments to write five things on a Post-It note that they could contribute to this initiative going forward. Everybody in the room, whether they were homeless or from a really wealthy foundation, wrote their five things. They sat in a room with the leader of the session after, and when we read them, we just cried ’cause it was so beautiful. People wrote everything from, “I will provide prayers. I will provide foundation money. I will provide volunteers to sit at the door of this organization. I’ll provide pet care for the homeless,” everybody has something they can contribute. When we look at it through that frame, there’s so much more we can get done.

Barilla: Yeah, that changes the conversation, doesn’t it, to one of abundance versus scarcity? I know Gary Gunderson is going around the country, looking at all the bright spots and all the great things that are happening. He often says if we just get out of the way of what’s already happening good and then just help it to happen more, we’d-

Hardin: Yeah.

Barilla: Be in a much better place just to what is truly the social fabric of our communities as we move forward into the future. But often we think of just looking at our health policy, this isn’t the conversation that’s happening on the national level. As we do think, perhaps, about some policies that can help support this work, what are your thoughts? What can we do in terms of a nation to help support some of this great, I think, organic community-based work?

Hardin: I think some of the policies that really have started to shift things, so value-based payment and some of the arrangements that start to incentivizes improving quality and decreasing cost, rather than increasing value of visits. That helps a lot. I think policies that allow creative interpretation of benefits. Some of the exciting changes we’re seeing talked about with the ability to use Medicaid waivers and other funding to potentially fund transportation or housing infrastructure. Then, any kind of incentives that allow sharing of resources amongst agencies, rather than competition for funding, from a policy perspective, tend to facilitate and accelerate change.

Barilla: That’s great. Then, in terms of, this is a little bit of a self-serving question but, what do you think an organization such as Providence St. Joseph Health can do to really help advance some of the needed changes?

Hardin: I think Providence is such a great beacon for change. I think large systems have an opportunity to light the way and show by example what can be done and highlight that. I’ve seen some really great things come out of Providence, everything from the investment in mental health and wellbeing to engagement and intentional seeking of care for vulnerable populations. The more large systems highlight that and the more large systems invest in that, other systems begin to see it as possible, desirable, it’s like looking up to your big brother to see what you should be doing, and thinking, “Well, if they’re doing that, then I should be invested in that as well.” Providence has done a great job with that, and continuing to share that message of the why and how, I think, is transformative.

Barilla: Well, that’s good to know that we’re being good partners in all of this work, Lauren, and just thank you for just all that you have done to help illuminate that pathway so that it makes it easier for large health systems to move along. But as we think about kind of the next chapter of the National Center for Complex and Social Needs, what do you see?

Hardin: There’s some really great work happening in the next phase of development to see how deeply can we develop partnerships that are generative across the country. The blueprint for complex care is just being released next week at our national conference. What that calls for is pulling together collaboratives of people across the country to start to define the core competencies to develop some regional networks, highlighting and supporting complex care work, to broadly share tools and resources that are moving this field forward, and to move forward the evidence around complex care and adding in space models. I think what you’ll see next is the next level of generation of more connection, more resources, and more collaborations with professional organizations as well as individual folks that are directly delivering care and consumers. That’s a key component in the blueprint, that people with lived experience are part of defining and moving this field forward.

Barilla: That sounds like an exciting next chapter, Lauren. Those of our listeners that are … you’ve really just inspired them today, is there anything that you’d like to leave with them in terms of how they can get more involved in this work, or is there anything else that you’d like to add?

Hardin: Sure. There’s so much opportunity to engage and be part of this movement. You can join our website at the National Center for Complex Health and Social needs. There’s free webinars, there’s ongoing gatherings, there’s a national conference, and there will be many more opportunities coming up in the next year to join the collaboratives moving this work forward. It’s also a great way to connect with others. Having worked with complex patients myself directly for the last 10 years, it’s very rewarding work, but it can also be very challenging. I think the more we connect with each other, we can carry this work together and share best practices so we understand it better, but also carry some of the grief and loss that comes with working with complex populations, so that what we see is a broader spectrum of healing across the country. So, please connect and join the list, connect with others, there’s lots of opportunities to continue to be involved and to grow in your practice.

Barilla: Well, Lauren, thank you for your leadership and for all the work the National Center for Complex Health and Social Needs is currently undertaking. We just really want to thank you for joining us today.

Barilla: For everyone listening, we look forward to our next topic and we look forward to your partnership improving the health of our local communities.