INTRODUCTION: As a result of new value-based payment models, health organizations are incentivized to monitor and address underlying social determinants of health (SDoH) that impact patients’ health outcomes. Data and technology innovations are central to the integration of clinical care, population health management, and multi-sector collaborations needed to address SDoH, particularly in safety-net settings. However, achieving this integration requires a better understanding of the intersections between patients, their environment, and the health system.

METHODS: We conducted a qualitative inquiry using: 1) in-depth interviews, patient-led neighborhood tours, and clinic visit observations of 10 patients with chronic illnesses from the public healthcare delivery system in San Francisco, focusing on patients in neighborhoods with higher rates of chronic disease overall; and 2) in-depth interviews and neighborhood tours with 11 community leaders from those same neighborhoods using the Streetwyze mobile mapping app. Guided by the Chronic Care Model (CCM), we explored the multilevel linkages between model components for vulnerable patients.

RESULTS: Numerous sources of social complexity, including homelessness and histories of trauma, influenced patient activation/engagement. Providers addressed patients’ social needs by adjusting their counseling and self-management support, and focusing on care coordination. Participants identified formal and informal local resources that are helpful for maintaining healthy behaviors; however, interpersonal relationships between community members and community organizations are a critical link to these resources. Broader community context including poor transportation and housing, as well as racial discrimination and gentrification, are structural barriers to patients’ disease management.

CONCLUSION: Our findings illuminate the community sphere of the CCM model, providing new domains for consideration to increase the impact of this framework as SDoH become more central to healthcare delivery systems. We will incorporate study insights into potentially improving existing platforms or generate new technology that can better communicate information between referrals for SDoH from the healthcare system and the community member/organization uptake of these services in everyday life.