The Primary Care Coalition (PCC), Nexus Montgomery hospitals, and community-based food assistance providers are partnering to create a Social Health Alliance in our community. Based on the social needs screening hospitals already do among inpatients, the roughly two-year project will create and pilot a system to coordinate referrals based on screening results and identify trends in community resource needs. Maryland Physicians Care has contributed nearly $500,000 to support the project.
“We are thrilled to partner on this important work bridging healthcare and health-related social needs for some of our most vulnerable community members: those who are hospitalized.” said Mindy Pierce, PCC’s Senior Director for Population Health and Nexus Montgomery. “The best hospital care can only do so much; many patients need a solid transition to community support too.”
Pilots in other communities have demonstrated the impact of blending medical and social treatment. The IMPACT project in Pennsylvania, for example, found that six months of personalized Community Health Worker support to address holistic needs – from help with medication refills to stress management through local art classes – made a difference for patients and healthcare costs. Intervention patients were less likely to be hospitalized, and hospitalizations tended to be for less severe needs than controls, leading to a projected annual return on investment of $2.47. All participating patients were low-income with multiple chronic conditions.
Our pilot plans to build on the current hospital screening point to create a more effective referral system. At the moment, many hospitals provide resource lists to patients who screen positive for social needs, but there is limited capacity for direct referrals. More importantly, hospitals have no visibility into provider capacity. If there is no way to direct patients to the best resource match, one food pantry might get multiple requests it cannot meet while another is underutilized. It’s a problem the Alliance aims to address, beginning with food insecurity.
When the project ends, hospitals should be better positioned to give tailored referrals for food assistance organizations ready to meet patient needs and the network of organizations will have improved communication and coordination. We will also have a better idea of our overall food assistance needs in the community, as well as where they’re located. We will have an aligned approach to whole-person health.
“We are thrilled to partner on this important work bridging healthcare and health-related social needs for some of our most vulnerable community members: those who are hospitalized.” said Mindy Pierce, PCC’s Senior Director for Population Health and Nexus Montgomery. “The best hospital care can only do so much; many patients need a solid transition to community support too.”
Pilots in other communities have demonstrated the impact of blending medical and social treatment. The IMPACT project in Pennsylvania, for example, found that six months of personalized Community Health Worker support to address holistic needs – from help with medication refills to stress management through local art classes – made a difference for patients and healthcare costs. Intervention patients were less likely to be hospitalized, and hospitalizations tended to be for less severe needs than controls, leading to a projected annual return on investment of $2.47. All participating patients were low-income with multiple chronic conditions.
Our pilot plans to build on the current hospital screening point to create a more effective referral system. At the moment, many hospitals provide resource lists to patients who screen positive for social needs, but there is limited capacity for direct referrals. More importantly, hospitals have no visibility into provider capacity. If there is no way to direct patients to the best resource match, one food pantry might get multiple requests it cannot meet while another is underutilized. It’s a problem the Alliance aims to address, beginning with food insecurity.
When the project ends, hospitals should be better positioned to give tailored referrals for food assistance organizations ready to meet patient needs and the network of organizations will have improved communication and coordination. We will also have a better idea of our overall food assistance needs in the community, as well as where they’re located. We will have an aligned approach to whole-person health.
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