Project Objectives

In its recent Community Health Needs Assessment, Lurie Children's found that social influencers of health, including poverty, education, family employment, housing insecurity and food insecurity substantially contribute to the health status of youth in Chicago.

All Hands Health Network (AHHN), led by Lurie Children’s, aims to expand access to quality primary care, specialty care, and behavioral health services while building care coordination and service integration capacity. AHHN is designed to adapt and synthesize existing resources where possible, improve care coordination for those served by Medicaid managed care organizations (MCOs), and build on existing Medicaid initiatives.  

The AHHN model service area (zip codes 60639 and 60651) encompasses a diverse cross-section of neighborhoods on Chicago’s Westside. Families from these neighborhoods report that they experience isolation, violence, and trauma in their communities; poor access to behavioral health services; and lack of coordination among core child service providers. Providers report lack of resources stemming from lack of sustainable payment for integration and coordination activities.

Model Goal

Create a socially and clinically integrated network inclusive of core child service providers ranging from community based social service organizations such as food pantries or housing providers, to governmental agencies/departments such as the Chicago Public Schools (CPS) or the Department of Children and Family Services (DCFS) aimed at:  

  • Improving health outcomes
  • Reducing impatient stays and out-of-home placements
  • Creating a sustainable Alternative Payment Model

Our Model

Figure1:

This graphic illustrates the interrelated components of All Hands Health Network's Socially and Clinically Integrated Network. These components are:

  • Alternative Payment Model
  • Annual Needs Assessment
  • Care Coordination
  • Behavioral Health Programs
  • Primary & Specialty Care Support
  • Data Sharing Infrastructure

  • We will bring together local pediatricians, specialists, behavioral health providers, and community organizations and institutions to address the medical and social needs of children and their families. 
  • We will focus on early identification of children’s physical, behavioral and social issues and rapidly connect families to appropriate local services. 
  • Service Integration Coordinators will ensure that health and social needs assessments are completed and children have access to the network resources.  
  • The integrated network will create enhanced communication and coordination between different agencies to remove the hurdles that families face when trying to access various services.
  • A new project-focused system will be developed to connect participating organizations and providers, manage interagency referrals, share assessments, and collect and analyze data to drive further improvements to the initiative.
  • The network will operate using a shared savings payment model, distributing savings from decreased healthcare spending among the clinical and social services providers.