Cedars-Sinai is unifying traditional medical care with social support. The health system has constructed a network to expedite referrals and link patients to more than 8,000 resources.

The Community Connect Program’s transformational framework is detailed in a recent NEJM Catalyst article.

In 2021, the program began cultivating robust partnerships with community-based organizations throughout Southern California. Program manager Krystal Green and the organizations developed a hybrid funding model to bolster regional capacity for social care. Cedars-Sinai invests targeted grants to cover gaps in the nonprofits’ operations, while referral pathways including community health worker support, training and service contracts smooth patients’ transition to care.

Read: Inspiring Community Health by Meeting Patients' Needs

"This approach meets partners where they are," Green said. "Being nimble is crucial to adapt to landscape changes."

The collaboration yielded an ecosystem of wraparound services for those with unmet social needs in areas such as housing, mental health, independent living and case management. Studies estimate social drivers of health are responsible for as much as 80% of health outcomes.

"We are preventing avoidable readmissions and Emergency Department encounters, reducing lengths of stay, and stabilizing patients," said Katie Hren, associate director of community health at Cedars-Sinai.

Cedars-Sinai and its affiliate hospitals have screened more than 66,550 patients.

Read: A New Type of Health Screening