In light of the increased interest from health systems in addressing social determinants of health through resource connections, United Way, 2-1-1 and Health Leads came together to publish a new whitepaper — Social Determinants of Health: Overcoming The Greatest Barriers to Patient Care — to share lessons from their decades of experience navigating patients to the essential resources they need to be healthy.

Many in the healthcare and social services fields know 2-1-1 as a free and confidential service that connects people to critical health and social resources.  And one of the most important services provided by 2-1-1 case managers is the life-changing connections they make with people who have long felt frustration in obtaining social, financial or health-related health assistance.

Staff at 2-1-1 often engage with individuals who have faced systemic barriers in securing the essential resources they need to be healthy — whether through government assistance programs or community-based nonprofit organizations. As one case manager shared:

“A lot of [our callers] are frustrated when they call because by the time they get to us they’ve called place after place after place. In February, a 62-year-old disabled school bus driver finally found 2-1-1 after spending two days without heat in her uninsulated trailer home where temperatures had dropped to -24°. She had run out of propane heat, out of cash to fill the tank, and out of state assistance because she’d spent too much already on soaring fuel costs.”

The threat of challenges like these are apparent, and front-line clinicians and social workers see first-hand how a lack of access to essential human needs affect health. The question is no longer why we must address social determinants of health — including safe housing, healthy food and more — but how we can best connect patients to the resources they need to be healthy.

To tackle complex social needs directly, health systems are increasingly seeking to build or source directories of services that are available to patients in their communities. While access to information is a critical first step, a directory alone is not enough to solve critical social needs challenges. Success depends on ensuring the information is comprehensive and current, that application guidelines and requirements are clear, and that staff or volunteers are trained to help patients navigate structural barriers.

That’s why United Way, an organization dedicated to improving lives by mobilizing communities to advance the common good, has joined with 2-1-1 and Health Leads to compile best practices in navigation and resource connection. Drawing on the three organizations’ decades of on-the-ground experience connecting patients with essential resources in their communities, the resulting whitepaper, Overcoming The Greatest Barriers to Patient Care, is designed to help healthcare and human service professionals implement more effective social needs interventions.

Among the key recommendations in Overcoming The Greatest Barriers to Patient Care:

Identify gaps in the local resource landscape and find ways to fill them.

Communities will not always have access to resources addressing 100% of their diverse social needs. Many healthcare organizations are opting to fill these gaps themselves. By offering on-site food pantries, distributing lunches, or supporting affordable housing, health systems are closing resource gaps investing in their communities in valuable ways and promoting health equity.

Identify the common barriers patients face when accessing resources.

There are pervasive structural barriers that prevent patients from accessing essential resources in their communities. From complicated application processes to cultural and language barriers, it’s critical to understand what may prevent people from accessing the resources they need.  

Track the outcome of each referral to understand effectiveness.

The only way to understand the success of your intervention is to track what happened after making the initial referral. Following up directly with patients to see if their need was met will enable you to continually maintain the quality of your intervention.

We hope the insights included in this whitepaper will help healthcare systems and community-based service organizations to create stronger, more effective social needs interventions. Through shared learning, we can build programs that ensure every person has access to the essential resources they need to live healthy lives.

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To learn more about how Health Leads can help your organization develop a social needs program, email us at solutions@healthleadsusa.org today — or visit the solutions section of our website.

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