Connecting the dots for patients and systems: Exploring a clinic-community linkage to address social determinants of health

Significant portions of the Cook County Health and Hospitals System’s (CCHHS) patient population live in social circumstances – unemployment, food insecurity, unstable housing – that prevent optimal health. It is estimated, for example, that 19% of County Care patients (medicaid patients served by CCHHS and partners) are housing insecure. CCHHS is not alone in serving patients with great social needs, and today’s health care institutions are often not readily equipped with the expertise or capacity to help patients effectively address social determinants of health.

LIFT is a nonprofit organization with a mission to “help community members achieve economic stability and well-being” by pairing clients with rigorously trained advocates to tackle their personal, social, and financial barriers to health.  LIFT-Chicago has a proven track record and reaches over 2,000 members annually. LIFT has the expertise and capacity to effectively address social inequities.

LIFT and CCHHS have begun exploring a multi-pronged collaboration: 1) to connect CCHHS patients with LIFT support during the clinic visit, 2) to gather at a “policy roundtable” to discuss and address institutional barriers to addressing social determinants of health, and 3) to explore sharing data around community-level factors and individual-level outcomes.  The local health department has committed partnership as well.

This presentation will 1) provide lessons-learned from the exploratory and implementation phases, 2) serve as a “how to” for establishing such partnerships, and 3) include an honest discussion of what went well and what could have gone better.