Community-engaged Lifestyle Medicine (CELM)

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As a dynamic Community Care Hub model, we work alongside you, our provider teams and health care partners, to deliver community-engaged lifestyle medicine through a collective impact framework by leveraging our role as an anchoring backbone to align local and regional efforts of diverse CELM partners around a common HEAL agenda for lasting, sustainable, compassion-driven health improvement. 

a Common CELM HEAL Agenda with Community Voice

• We define HEAL needs Collaboratively: We work with all stakeholders (CBOs, healthcare providers, community members, public health departments) to agree on a shared vision and a clear definition of the specific health issues to address  (e.g., reducing type 2 diabetes incidence through the Full Plate Living lifestyle change program).
• Incorporate Authentic Local Voices: We work to ensure the governance and decision-making processes include authentic  community representation. This builds safety and helps ensure programs offered through the Grace Hub are respectful, considerate, culturally responsive and tailored to our community's unique needs,  priorities, and lived experiences. 

Shared Measurement Systems

• Common Metrics: We work with you and all participating organizations to agree on a set of common  indicators to measure success consistently (e.g., changes in physical  activity levels, fruit/vegetable consumption, blood pressure control).
• Centralized Data Collection and Reporting in Thrive Hub: The GraceHub, acting as the backbone, manages the data infrastructure for you. This  involves using a shared technology platform (e.g., Thrive Hub by SC Thrive) to track client progress, measure outcomes, and report metrics back to you securely as our healthcare partners, ensuring  data integrity and privacy while reducing the administrative burden on individual  CBOs.
• Data-driven Continuous Improvement: We regularly collect and analyze data to learn from both successes and challenges, refine strategies, and demonstrate the value of CELM interventions to payers (e.g., Medicaid and Medicare plans). 

Coordinating Mutually Reinforcing Activities

• Leveraging Diverse Expertise: The CCH coordinates a wide network of CBOs (e.g., YMCAs, food banks,  senior centers, mental health services) so that each organization can provide the services they excel at in a coordinated manner.
• Integrating Clinical and Social Care: Facilitate seamless, multi-directional referrals between healthcare  systems and CBOs. This ensures participants receive both medical care  and essential social services (like housing or transportation  assistance) that address the social drivers of health impacting their  ability to adopt a healthy lifestyle.
• Providing Holistic Support: CBOs can offer a range of interconnected lifestyle medicine programs  (e.g., nutrition education, physical activity classes, chronic disease  self-management support groups), leveraging economies of scale to  provide a comprehensive "no wrong door" approach to care. 

 Commitment to Continuous Communication

• Foster a Culture of Collaboration: The backbone organization must facilitate frequent, structured meetings  and ongoing communication among all partners to build trust, share  information, and resolve differences.
• Engage Community Health Workers (CHWs): Utilize CHWs, who often have lived experience and trusted relationships  within the community, as a vital link between participants and the hub  network. They can provide tailored support, help navigate complex  systems, and ensure culturally appropriate communication. 

a Dependable Anchor in Shifting Tides

• Centralize Operational Support: The CCH provides the necessary infrastructure and dedicated staff to  manage administrative functions, contracting, billing, and quality  assurance, allowing frontline CBOs to focus on service delivery.
• Secure Sustainable Funding: Transition from unpredictable grants to sustainable contracts with  healthcare payers, leveraging the collective's scale and proven outcomes  to negotiate effectively and ensure appropriate reimbursement for  lifestyle medicine and social services. 

These resources detail how the GraceHub, as a local Community Care Hub in Allendale County, is leveraging collective impact to foster collaboration, coordinate services, improve chronic disease management and health outcomes  for community-engaged lifestyle medicine by enhancing provider capacity to deliver high-quality care, elevate provider and patient experiences through community-engaged lifestyle medicine, and increase innovation, health literacy, and adoption of best practices in rural health by continuous improvement and excellence in adaptively applying what works for our communities.