The Dimock Center has a long history of being a trailblazer in community health. More than 150 years ago, it started as the New England Hospital for Women and Children – created for women, by women. As the first hospital in the country to launch a nurse training program, the Dimock Center took its belief in transformation and learning to a new level, when in 1969, it became a community health center in the Roxbury neighborhood of Boston, Mass. Now, Dimock is nationally recognized for its breadth of programs in community health, child and family services and behavioral health.

Clinicians and staff at the Dimock Center have experienced how expanding their traditional understanding of what matters in health can have a lasting impact on patients. Not only does the Dimock Center help patients with primary care needs, but it has an early childhood education program that blends learning with health. Eye doctors and dentists from Dimock routinely make visits to the center’s preschool programs so kids can start out healthy. The Dimock Center is also open seven days a week, including evening and weekend hours, so patients don’t have to choose between their health appointments and going to work.

President and CEO Dr. Myechia Minter-Jordan says the key to being a leader is to be a community partner. Dr. Minter-Jordan and the rest of the Dimock team have spent much of their time growing programs, developing relationships with local hospitals and community based organizations, and working to provide the best services possible for patients. With services reaching more than 18,000 people annually, Dimock staff will tell you, the focus on patient-care doesn’t stop with a doctor’s visit, but extends through the full spectrum of health. It’s a view that includes addressing people’s essential needs like food, housing, employment and education and continuing their long tradition of believing in the strength and resilience of the human spirit.

Michigan’s Upper Peninsula (UP) is a rural area that covers nearly a third of the state’s land area – stretching a few hundred miles – but is home to only 3% of its population. As a result, the residents and community members of UP often have to put in the extra mile to access the essentials we all need to be healthy, as compared to more urban areas which typically offer a denser concentration of resources. For this reason, the Upper Peninsula Health Plan takes the job of screening members for essential resource needs very seriously.

Starting in June of 2016, UPHP began the Connected Communities for Health (CC4H) program. Working with faith-based, community and state organizations, UPHP strives to meet its members’ essential needs. Members who call with a question about their health plan are also asked whether they need assistance with housing, transportation, education, child care, food, or utility assistance. If they do, the members are then transferred to a call center where they can talk to medical interns who have been trained by UPHP as part of its innovative workforce model to address essential needs.

In one case, a woman and her two children were living in a house that was not structurally sound. The house was missing walls, electricity and heat because her husband had not finished building the house before the couple divorced. While working with the health plan member, the intern was able to help with energy assistance and connected her to Habitat for Humanity to complete the needed renovations. This is one example, from hundreds of cases, where an Upper Peninsula community member has been helped by UPHP to have their essential resource needs met.

Two years after starting the CC4H program, UPHP leaders say the program is scalable with the hope of unveiling the program in community hospitals, clinics and health departments across the region – another example of how one innovation that may start small can have a big impact on people’s health and wellness – no matter where they live.

Spanning 36 blocks and named one of the largest pediatric hospitals in the country, Arkansas Children’s Hospital has a vision for child health that is just as big as its’ physical presence in Little Rock. Talking to parents and making sure they have adequate housing, food, and education became a priority for the hospital back in 2015. In less than two years, one of its’ clinics, the Circle of Friends, reached out to nearly 26,000 patient families to offer support in meeting their essential resource needs – about 76% of total patient visits.

This focus on social health hasn’t been easy, and has required a shift in how the hospital and its’ employees view and address clinical care. For Arkansas Children’s Hospital, it was the fourth try by hospital leadership to create a sustainable essential needs intervention that led employees to realize the seriousness of what was being asked of them. It took time for staff to understand- their commitment to this work could literally change patients’ lives-by putting food on the table and keeping a roof over their heads.

Arkansas Children’s couldn’t have done this work so well without the backing of its’ nurses. By taking the lead, nurses at three of the hospital’s primary and specialized care clinics were able to be change agents for improving health outcomes and connecting families to community resources. They partnered with physicians, social workers and medical-legal staff to make sure families avoided homelessness, secured and maintained health insurance, and received educational support. Program leaders championed the change by including perspectives and input of all clinic staff, addressing barriers right away, and making adjustments based on staff and physician feedback.

Now, three years later, staff and physicians are working together to integrate all the social health data they’ve collected into the organization’s electronic medical record. While the journey toward social health integration wasn’t without ups and downs, Arkansas Children’s perseverance and dedication to the families they serve is a model for us all.

Walk into the Health Leads’ office at the Harriet Lane Clinic (HLC) at Johns Hopkins Hospital and you can’t miss the large supply of kids’ winter coats, backpacks and school supplies. At HLC, the idea that something can’t be done doesn’t cross anyone’s mind. It’s a team effort to make sure kids at the clinic get whatever they need to be healthy.

Clinic staff and providers aren’t the only ones driving this mindset. The clinic has a parent advisory board and community health workers who help bridge the gap between clinic centered care and community health. Now, more than a decade after the clinic started a social needs program, former Clinic Director and current Interim Division Chief of General Pediatrics and Adolescent Medicine, Dr. Barry Solomon, would like to see parents taking their involvement to the next level.

“We’d like our parents to be mentors, liaisons, and be a part of the decision-making process,” said Solomon. “We want to see them being parent navigators for children’s social needs and mentoring other parents to navigate the complex health system.”

Co-creating patient care isn’t something new to HLC. Over the years, the clinic has been a beacon of collaborative care. The clinic partners with various community-based organizations in Baltimore to make sure mothers can access diapers for their babies, parents can find jobs, and families live in safe housing. When a new need develops for patients, staff are quick to apply for grants that allow them to meet that need.

Dr. Solomon remembers what it was like before the clinic started this work. The team knew something needed to be done, but just wasn’t sure how to do it.

“We knew challenges outside of clinical care existed, but we didn’t have a full way to address those needs or connect to the community in a meaningful way. It’s not just about referring patients to resources but making sure they get connected and knowing how that connection made a difference in their health.”

And that’s what’s been happening. Now, nearly 2,000 patients a year are seeing their care at the clinic expand to more than what happens in the exam room. Dr. Solomon says doctors are collaborating with patients to address their full health and it’s making a difference!

VP of Population Health Katy Bazylewicz on how Cottage Health involves both data and input from its community to address people’s social, mental and physical needs.