Driving Innovations in Care Coordination

ARCHI’s 28-year commitment is based in the science that recognizes the powerful role that housing, education, jobs, food and nutrition, safe, quality communities play in creating health and wellbeing. ARCHI partners are coming together to drive innovations in care coordination to address these needs and measure the impact on health.

DeKalb Youth Prosperity Initiative embedded a Resource Navigator into the Peachcrest Elementary School to address social, health or economic needs of families within and around the school community.

Community Resource Hubs launched at Mercy Care and Grady that match Community Health Workers with patients and utilizes a closed loop partner network to address housing, food, transportation, legal and employment needs.

The Diabetes Collaborative provided telephonic coaching to unmanaged diabetes patients to address their social and economic needs and finished Phase I of the initiative.

The Value-Based Collaboratives completed the design of a payment model targeting the community needs of recently hospitalized congestive heart failure patients with lower socio-economic status.

ENGAGING & INFORMING THE COMMUNITY IN 2020

Supporting Education and Dialogue
on Health and Racial Equity

ARCHI continued its commitment to examine the policies, practices and prejudices that have created the inequities impacting the health of many Atlantans in 2020 by holding in-person and virtual learning sessions in conjunction with many different partners. ARCHI provided almost 20 hours of programming, engaged over 1600 individuals and focused on a range of topics including Race and Homelessness, Policing and Health, Health Equity and the COVID Crisis, the facts about the COVID Vaccine and Atlanta’s recent ranking of health and race as key community priorities in the annual Metro Atlanta Speaks Survey.

Weekly Hospital Coordination
The care coordination teams of the six metro area
health systems meet weekly to identify resources
and other partners to better serve patients. While this
initially focused on COVID positive patients, it has
expanded to individuals with substance abuse and
mental health needs

Spreading Critical Public Health Messages
ARCHI partners committed to sharing critical public
health messages to both prevent COVID and to
increase access to the vaccine. They spread the
word through their channels and networks and
integrate public health messages into their services
and outreach.

Integrating Health and Housing
ARCHI partners came together to align services and
resources to help individuals who were temporarily
housed to keep them safe from COVID-19 find
permanent and supportive housing. Many of these
individuals were older and/or had chronic conditions
so by aligning services, partners were able to more
quickly integrate health and housing.

Investing in Housing to Address Health
Six health systems and insurers made a commitment
at the end of 2019 to develop a shared investment
strategy to support affordable housing in metro
Atlanta. While their timeline was shifted by the
pandemic, several partners did make initial
investments and the group met regularly to discuss
the changing housing crisis. They will continue their
work toward an investment strategy in 2021.

Collaborating in the Time of COVID
ARCHI along with United Way has been supporting
Colabs, a partnership of 13 collaboratives with
different missions but common commitment to
collective impact. Special virtual sessions in 2020
focused on identifying the shared challenges and
building skills to foster collaborative work within
a pandemic

Partnering with the CEAL Coalition
ARCHI is partnering with the CEAL Coalition hosted
by the Morehouse School of Medicine to develop
tailored messaging and outreach to communities
hardest hit by COVID-19. Launched in December
2020, this collaboration is sharing the latest
information about the COVID-19 vaccine to increase
vaccine uptake.