The most vulnerable patients are still falling through the cracks or not the getting needed health care services to improve outcomes and health. Our broken health care systems don't meet the health care needs of all patients. There is no one setting at fault or who can improve the system alone. Unfortunately, we have been working in silos of care on different goals - until recently.

Healthcare reform is an exciting, but challenging time. There are great opportunities to work cross- setting(s) towards the IHI's Triple Aim goals of improving patient outcomes and satisfaction, improving care for all populations, and reducing healthcare costs.

So where do you start with reaching out to other organizations to create collaborative efforts?
Simple Tips for Creating Health Care Collaborations on page 21 of the Underserved Population Best Practice Intervention Package (BPIP) may jumpstart your brainstorming on creating collaborations. Decide on the specific setting and what partners you could you reach out to - think out of the box. The table below can help you get started with some simple ideas and resources.

Collaboration Opportunities	Resources
In-Patient Settings Hospitals Nursing Homes (NH) In-Patient Rehab Units (IRU) Long Term Acute Care Hospitals (LTACH) Possible topic areas Focus on reducing hospitalizations or readmissions Improve care transitions Utilize post-acute care providers effectively	Cross-Settings I BPIP Focus is on care transitions, health coaching, SBAR communication, discharge worksheets, and other tools/resources Care Transitions: Special Barriers/Issues for the Underserved UP Teleconference Evidence-Based Health Coaching - The Newest Trend in Patient Engagement Webinar National Transitions of Care Coalition's Improving Transitions of Care: Hospital to Home
Post-Acute Care Providers Emergent Departments & Urgent Care Centers Primary Care Practices Health Centers (including HRSA centers) Area on Aging Associations (AAA) Possible topic areas Focus on reducing hospitalizations or readmissions Improve communications Utilize post-acute care providers effectively Improve follow-up care Address social/economical needs	Best Practices for Care Transitions: Engaging Emergency Departments & Urgent Care Centers UP Webinar Underserved Population BPIP Doctor Reminder Notice (patient tool) ©Morisky Medication Assessment (clinician tool) Cross-Settings I BPIP Physician engagement (pp. 54-55; 68) SBAR Communication (pp. 56-63) National Transitions of Care Coalition's Improving Transitions of Care: Emergency Department to Home
Pharmacies Reach out to community and chain pharmacies to create a network Request staff education sessions on high-risk or problematic medications, medication management solutions, reconciliation, etc. Develop strategies to address community and patient issues: Access including delivery Adherence Fall Prevention Financial barriers Medication reconciliation Communication with physicians	Medication Management BPIP (Focused) Improving Management of Oral Medications BPIP Underserved Population BPIP (pp. 51-53) ©Morisky Medication Assessment (clinician tool) Gravity of Falls - The Evidence-Based Preventative Strategies Webinar Duquesne University's Community Pharmacy Initiative UP Teleconference
Mental Health Centers Research all available services Discuss opportunities to bridge patients from one setting to the other Troubleshoot for unmet needs Share education cross both settings Ex: Behavioral health topics, home health benefit, patient engagement strategies, etc.	Alzheimer's Disease: A New Way of Understanding for the Home Care Worker UP Webinar Community Mental Health on Wheels UP Webinar Underserved Population BPIP (pp. 47-50) Success Story - Behavioral Health Issues & Home Health Care - A Holistic Approach
Community Outreaches Flu clinics Include BP, glucose, or fall screenings Provide other health education	Diabetes Risk Assessment & Prevention in Disease Management: Diabetes (Focused) BPIP Everyone with Diabetes Counts: The Impact on Rural Southern West Virginia UP Webinar Gravity of Falls - The Evidence-Based Preventative Strategies Webinar
Food Bank Organize a food drive at the agency for donation Offer education or create a list of healthy food donations or for disease specific boxes (e.g., Diabetic, Heart Failure) Provide a list of local food banks with location, times, requirements, etc. to all potentially needy patients Offer screening for food bank participants (e.g., BP, glucose) and offer education	Improving Patient Outcomes with Early Intervention to Fill Nutritional Gaps UP Teleconference Underserved Population BPIP (pp. 54-58)
Faith-Based Organizations Establish contact person(s) at organizations Discuss community needs and how the organization could assist Ex: Transportation, clothing, food, housing, etc. Offer screenings or education Ex: Cardiovascular Health, Diabetes, Falls Prevention, Palliative and Hospice Care, etc.	Underserved Population BPIP (pp. 10; 32) 100 Congregations for Million Hearts®
Insurers/Payers Discuss collaborative and pilots with managed care organization Develop relationships with Medical Assistance organizations to improve communication Begin care planning for dual-eligible patients upon Medicare admission for seamless transitions and obtaining needed services	Population Health Management from Home Health Perspective UP Webinar (7/9/14) Underserved Populations: A Managed Care Perspective UP Webinar Coordinating Medicare & Medicaid UP Webinar Making the Most of Telehealth to Care for Underserved Populations UP Webinar Underserved Population BPIP (pp. 15-20)
Academia Create partnerships or internships to assist with education, research project, data analysis, assist with other collaborations, etc. Find graduate students for home health focused project, thesis, and/or dissertation	Duquesne University's Community Pharmacy Initiative UP Teleconference