Pilot of a centralized national social service utilization support call center

Social barriers disproportionately limit low-income and disadvantaged populations as well as individuals with disabilities in accessing health care.  At the same time, the network of social services (called the Social Safety Net) operates on a shrinking budget and faces significant, ongoing funding threats while the need for services resulting from the 2009 Great Recession continues to rise. 

The social service utilization support model responds to the threat to the Social Safety Net and the need to quantify the impact of social services on health outcomes.  Using a team of community health workers, researchers catalogued available social services across 48 states and captured this data within a centralized database.  This database is then used by peer-support specialists to refer individuals to the social services and create a corresponding social service electronic health record. 

The focus of this discussion is the design and use of a centralized national social service call center and a social service electronic health record in guiding individuals in resolving social issues, and, by extension, evaluating the impact of addressing social issues that act as barriers to accessing healthcare as measured by decreased cost and increased preventive compliance.

More than 2,000 people have been referred to more than 6,000 social services through the centralized peer-support call center.  The call center is manned by 32 individuals hired through Ticket to Work, Welfare to Work and other workforce innovation programs.  Each person assisted receives follow up and the referral is captured within their individual social service electronic health record.