Building a Care Coordination Program: Addressing Determinants of Health and Well-being

6 minute read

Building a Care Coordination Program: Addressing Determinants of Health and Well-being

< 1 minute read

Medical Center Health System Designed and Implemented a Community Health Department to Build a Healthier Community

The Issue

In 2013, Medical Center Health System, located in Odessa, Texas, embarked on a journey to create a healthier community. We knew we had a long way to go. Our county health rankings weren’t favorable according to the County Health Rankings from the Robert Wood Johnson Foundation, and we didn’t yet have a department at our hospital to address our community’s many health needs. We knew we wanted to approach the issues from the community angle but also from the hospital perspective. Our hospital understood that to build a “Culture of Health” we needed to be innovative and think beyond the traditional four hospital walls. We wanted to design a program that centered on the medical well-being of the patient but also addressed the determinants affecting our residents’ health. We also appreciated the fact that we needed to be creative to make best use of our existing resources and available health care providers.

What We Tried

We started our Community Health Department in August 2013 with one nurse leader, and the department has grown significantly from there. Our focus is two-fold: community education/engagement and in-hospital care coordination services leading to a safe and effective transition home.


From the community education and engagement perspective, we lead a community-based DSHS (Texas Department of State Health Services) grant and corresponding health care coalition. The grant is focused on reducing avoidable hospital readmissions through care coordination, community education and health care provider education. The Ector County Health Care Coalition is composed of key community members representing education, public and private sectors, and nonprofit agencies as well as other leaders with an interest in improving the health of our community. The coalition’s focus is to provide an abundance of community education and thus create engagement across various public sectors. Additionally, all members of the coalition are able to refer residents to the many services available through the hospital’s Community Health Department.


We also created the Faith & Health Network, led by a nurse navigator, which partners with several dozen local congregations of various denominations. Through this network, we involve congregation members in health promotion events, including health fairs, walking clubs, health challenges, public lectures, individual health screenings and counseling, and a “drive-through” blood pressure clinic. To date, more than 2,000 individuals have joined the Faith & Health Network and benefited from these health promotion events.

Community Events1 dian-ruiz-picture2

At the hospital, we now have an interprofessional team of 27 health care professionals, including nurses, respiratory therapists and social workers. Our services reach thousands of patients each year. To date, we have helped more than 14,000 patients transition safely into the community and enjoy healthier lives. We created a care coordination model comprised of four key team members per patient care unit: two inpatient care coordinator nurses, one social worker or care transition coordinator, and one community nurse navigator.


Working with physicians, patients, family members and other key health care team members, we have redesigned care coordination and discharge planning for our patients. Patients in the hospital are thoroughly assessed after admission, and individualized care plans are developed to meet medical, social, financial and physical needs. At daily care briefings, team members discuss any care concerns and plan for safe and timely patient discharge. They connect patients with the necessary resources to transition safely back into the community setting. Our team works with physical therapists, dieticians, physicians, speech therapists and others to meet the complex medical needs of our patient population.


Upon discharge, patients are transitioned to the care of a community nurse navigator. The navigators form close relationships with patients and can follow them for weeks and months–and years, if necessary. Navigators help patients meet their medical needs while simultaneously addressing determinants of health that may be impeding the patient from living a healthy lifestyle. Our teams have successfully helped county residents access consistent transportation, meals, jobs, housing and funding sources.


As mentioned previously, we have served more than 14,000 patients in our community. Prior to implementing this program, our hospital had no formal post-discharge follow-up process for high-risk patients. We didn’t have the resources or processes in place to meet patients’ needs in the community once they were discharged. Discharge planning has taken on a new meaning in transitioning patients home safely. The program’s influence has grown significantly since its inception, and we now cover the majority of the patient care units within our hospital.


Since the program began, we have served more than 14,000 patients in our community by growing our team to 28, expanding to four patient care units and leveraging community partnerships to meet complex population health needs. We also have served more than 2,000 community residents via the Faith & Health Network. We have held hundreds of community events and public lectures and conducted thousands of health screenings to promote healthy lifestyles.


Our hospital readmission rates overall have decreased, with most diagnosis bundles now well under the CMS 1.0 readmission index. We expect ongoing improvements as we continue to engage the population at large. Overall hospital length of stay for patients has decreased significantly due to the coordinated care planning led by our team of care coordinator nurses and social workers/care transition coordinators.


Many of our patients have participated in local news interviews explaining the impact that our services have had in their lives. Patients have called their nurse navigators “angels” and “lifesavers.” One nurse navigator was able to get a wheelchair ramp built for a patient so that he could get in and out of his home more easily. That patient is now a volunteer at our hospital and still connects often with the nurse navigator.

Readmission Index Ratios

Readmission index ratios continue to improve in all diagnosis-related bundles as a result of this interprofessional model.


The care coordination model we designed can be replicated and easily modified to meet the needs of other communities and hospitals. We designed our program based on the unique features of other care coordination and community health initiatives found across Texas and through literature searches. We took “the best” of each model and then designed our own plan, based on the availability of resources locally. Each element of the model, from the inpatient and community perspective, can be tailored to meet specific population health needs. Flexibility is key when designing such a program. We completed many PDSA cycles, including relaunching the entire program after scaling down for a few months to redesign the overall model. There is no “wrong” way to do this as long as you are always focused on the outcome—creating safe and effective transitions of care for patients.

Organizational Background

Organization Name: medical center

Location: 500 West 4th Street, Odessa, TX, United States

Organization Type: Hospital