United Way of Greater Cleveland has long been involved with social service efforts that would seem by common sense to benefit health outcomes, but until recently there have been few national efforts to demonstrate such effects.
That changed in 2017 when Greater Cleveland was awarded one of 28 Accountable Health Communities (AHC) grants by the Centers for Medicare and Medicaid Services Innovation Center. The five-year, $4.51 million project, which wrapped up in Cleveland earlier this year, was designed to pilot a transformative new model of healthcare service provision— specifically to determine if addressing health-related social needs would positively impact Medicaid and Medicare beneficiaries by reducing costs and improving quality of life.
United Way tapped its existing 211 program — the service whereby people in need can call any time and be connected to a trained navigator — and embedded navigators into seven area hospitals and health clinics to offer patients screening for specific social service needs that are known to impact health such as housing, food, and transportation.
More than 75,000 people were offered screenings for social needs at participating clinical sites, and qualifying individuals were enrolled in ongoing navigation activities with United Way 211 navigators. United Way served as the bridge organization for the project, with clinical partners including Cleveland Clinic, MetroHealth, and Sisters of Charity Health System.
According to Jennifer Kons, United Way’s Director of Strategic Initiatives, “before we started AHC, several of our Advisory Board members, particularly in the healthcare and public health arena, were focused on identifying and addressing health disparities, specifically racial inequities, and recognized the impact of unmet social needs like food and housing. It was certainly on people’s minds, but organizations didn’t necessarily have all the infrastructure.
“When United Way proposed AHC, the health systems and providers that we worked with were interested and excited. The direct service portion of the AHC project is ended. Over the time that we were embedded with healthcare providers, our health partners worked to create their screening and referral processes to identify and address health-related social needs. It was great to help kickstart some of their direct efforts to support patients.”
Evaluation of the program at the national level is still underway but early findings point to fewer emergency department visits for select participants.
“One of our big takeaways,” says Kons, “was that it’s very complicated. For example, we screened people for social needs and identified resources they might qualify for, but it was challenging for individuals to set aside time from work and their families to pursue available resources. We also identified needs that didn’t have immediate options, such as gaps in meal delivery for some groups or too few options for quality, affordable housing.
“We need service navigation to help people access what’s out there, resources to support economic mobility, and policy solutions to improve the safety net.”
United Way is now working to better understand and respond to the experiences of individuals participating in navigation and the agencies serving them, questions which grew out of participant focus groups conducted by Case Western Reserve University Center on Poverty and Community Development.
This exploration is part of an Ohio Health Improvement Zones (OHIZ) project funded by the Ohio Department of Health focused on making neighborhood-specific community-driven changes for social determinants of health. In partnership with Burten, Bell, Carr, and Better Health Partnership in the Central, Kinsman, and Buckeye neighborhoods, United Way is soliciting resident and agency feedback on referral and navigation, findings which can inform United Way211, health care, and all organizations seeking to address health-related social needs.
