Cedars-Sinai ‘Connects’ Patients and Community to Key Services
The ‘Community Connect Program’ Will Boost Screening for Patients With Health-Related Social Needs
Common life challenges such as crowded living conditions, lack of food and financial stress often contribute to poor health outcomes but are overlooked until a patient lands in a doctor’s office or an emergency room. To help patients and others in the community overcome these kinds of obstacles, Cedars-Sinai has launched the Community Connect Program to enhance screenings for health-related social needs and improve referrals to social service agencies in the community.
Through the new program, Cedars-Sinai community health workers will assist particularly vulnerable patients to make sure they get the extra help they need by making home visits and helping patients with phone calls to set up appointments. The community health workers will support patients from the Cedars-Sinai emergency department, the ambulatory care management team and three other inpatient and outpatient units.
Otherwise, the Community Connect Program’s services will be available for all outpatient and inpatient units of the medical center, the extended medical network and Cedars-Sinai Marina del Rey Hospital.
“This is part of a broader Cedars-Sinai vision to truly care for the whole person,” said Jonathan Schreiber, vice president of Community Engagement. “If someone comes into the emergency department, they may have a primary complaint. But while we are treating them, we may find out that there are other ways we can connect them to critical services and care that they may require to be healthy.”
The necessity of programs like Community Connect are spelled out in an influential 2015 study published in the American Journal of Preventive Medicine, titled “Relationships Between Determinant Factors and Health Outcomes.” It found that up to 90% of community health outcomes stem from living conditions known as “social determinants of health.” Factors include whether community members are well-housed or homeless, live in safe or dangerous neighborhoods, and whether they experience food security or insecurity.
Such information will be consolidated in Cedars-Sinai patients' electronic medical records to highlight any health-related social needs they may have. Social workers, case managers, psychiatrists and other physicians can access that information in one place, rather than across the platform.
“Anybody who touches the patient’s chart can know immediately what potential barriers the person is dealing with,” said Katie Hren, LCSW, MPH, manager of the Community Connect Program.
Addtionally, an electronic connection is being added to CS-Link, the electronic health records system, to help Cedars-Sinai patients and providers find social service agencies for referrals.
A separate, public-facing version of the tool, called CS Community Resource, was developed in partnership with Aunt Bertha, a social care network that connects people and programs. This resource will be available on the Cedars-Sinai public website for both patients and non-patients on the Community Connect web page. Users can search for a term or look for free or reduced-cost resources organized into 10 categories: food, housing, goods, transit, health, money, care, education, work and legal.
Cedars-Sinai also is building partnerships with some social service providers so that referrals can be made and tracked electronically to try to ensure that follow-up is taking place. The system will provide updates on whether a patient is following through with weekly outpatient mental health appointments, for example, or if someone struggling with food insecurity has visited the food bank.
The new system will enable Cedars-Sinai “to ensure that no patient falls through the cracks,” Hren said.
Meet a Cedars-Sinai social worker on the Cedars-Sinai Blog: Faces of Cedars-Sinai: Social Worker Gabrielle Clay