A new study explored whether connecting patients to United Way 211 through primary care clinics could improve health by addressing basic needs like food, housing, and utilities.
The results showed that building a clinic-based referral system using electronic health records is possible, and 211 was able to provide resources for an average of three needs per patient reached. While immediate health improvements weren’t found, existing research on basic needs and long-term health suggests the value of further study.
A doctor’s visit that goes beyond medicine
What if a doctor’s visit addressed not only immediate health needs, but also basic needs like food assistance, housing help, or transportation support?
A recent study published in Medical Care explored a model for achieving this by partnering primary care teams, United Way 211, Better Health Partnership, and local health systems. The study tested a scalable program connecting patients to community resources through their electronic health records, making it easier to address basic needs that affect health.
Instead of giving patients a phone number or pamphlet, clinic staff referred them directly to United Way 211 using the electronic health record system. We then reached out to patients, identified their needs, connected them to local resources, and submitted an update to their patient record. This created a “closed-loop” process where the referral had a clear outcome documented in one place.
Why addressing basic needs is vital to health
The program aimed to address patients’ non-medical needs, because basic needs have a direct impact on health. In public health, these factors are called the social determinants of health—the conditions in which people live, work, and age that shape health outcomes. When core needs like food, housing, or transportation are unmet, it is harder to manage chronic conditions, recover from illness, or stay well in the first place.
By building a direct link between clinics and our 211 service, the model reduced the burden on patients to find help on their own and made it easier to connect them to the right services quickly.
Our 211 is uniquely equipped for this role. With a large and continually updated database, we can provide information about support services with an unmatched level of detail and accuracy. We have multiple full-time staff members who maintain our database of 10,000+ local programs, ensuring that people get referrals to resources that are current, relevant, and appropriate.
Key study findings
- 1,224 patients were referred to United Way 211 during the program
- About 38% of patients were reached by 211 navigators
- Every reached patient had at least one identified need (average: three)
- Most common needs: food assistance, help with housing costs, and utility support
- On average, patients were connected to ten community resources
- 87% had at least one need resolved or in progress toward resolution
What the results mean for the future
Although the study did not show immediate health gains from clinic-based 211 referrals, this approach may still play an important role in improving health over time. The impact of the social determinants of health on long-term outcomes is well understood, and a first referral for help can lay the foundation for lasting improvements. The authors conclude that linking clinics to 211 to address patients’ basic needs is feasible, but more research is needed to develop the most effective model for measurable health improvements.
As Greater Cleveland continues to strengthen links between healthcare and community support, United Way 211 remains a trusted, proven tool for helping people navigate the everyday challenges that shape their health and well-being.
This article was drafted with the assistance of generative AI, and edited and fact-checked by the author.
