This project, led by Marshfield Clinic, aimed to change the way clinics, campuses and communities interact to advance health equity by refining and expanding the Community Connections Team (CCT) model to screen for and address unmet social needs. The CCT model recruits, trains and supervises volunteers to connect patients with unmet social needs to community agencies for assistance. Traditional health care systems excel in treating illnesses through medication, therapy or procedures but often fall short in addressing upstream social factors that significantly influence health outcomes. Systematic screening for social needs is rarely part of routine care, leading to many patients not receiving the necessary referrals and support.
This project successfully advanced health equity by screening over 54,300 individuals for social determinants of health (SDOH) needs and facilitating 11,361 referrals to community agencies, connecting patients with baby needs, dental care, housing and more. The integration of Findhelp into Marshfield Clinic Health System’s electronic health record system expanded access to a directory of social care programs via a ZIP code search. Additionally, the project trained and supported 154 volunteer navigators who collectively contributed over 15,500 hours to bridge health care gaps and promote health equity through community resource navigation.
The Challenge
Marshfield Clinic Health System Community Connections Team
Traditional health care systems excel in treating illnesses through medication, therapy or procedures, but often fall short in addressing upstream social factors that significantly influence health outcomes. Many patients have unmet social needs that significantly impact their health, with evidence showing that only 10 percent of health outcomes are driven by medical care, while 90 percent are influenced by social, behavioral, environmental and other factors. Addressing these upstream social needs is crucial for improving health outcomes and achieving health equity. Despite recognizing these barriers, health care providers face challenges such as limited reimbursement for social determinant services, insufficient staff support and time constraints. Systematic screening for social needs is rarely part of routine care, leading to many patients not receiving the necessary referrals and support.
The Community Connections Team (CCT) model, developed by Marshfield Clinic, Family Health Center of Marshfield, Inc. and the University of Wisconsin-Eau Claire, recruits, trains and supervises volunteers to connect patients with unmet social needs to community agencies for assistance. In the clinic setting, patients are screened for social needs and trained volunteers discuss these needs to make referrals to appropriate resources. Volunteers continue to follow up with patients until their needs are met. Since its launch in 2015, the CCT model has been piloted in Wisconsin’s Chippewa Valley at several Marshfield Clinic locations.
Project Goals
The overarching goal of this project was to change the way clinics, campuses and communities interact to advance health equity by refining and expanding the CCT model to screen for and address unmet social needs. This goal was approached through four main objectives:
Develop an inclusive governance structure that engages and empowers all affected constituents and interested stakeholders, refining the existing CCT model to authentically engage those affected by health inequity.
Strengthen the ability of the next generation of healthcare professionals and citizens to think critically about health equity through volunteerism in CCT.
Evaluate the impact of the CCT model on patient health outcomes to demonstrate the effects of universal screening and intervention for social needs on patient health outcomes.
Establish the potential for model replication as an economical, effective and sustainable way by which the social determinants of health (SDOH) can be identified within the healthcare setting to advance health equity.
Results
This project has made significant strides in advancing health equity and addressing SDOH through comprehensive community engagement and strategic partnerships. Since its inception, the project has screened over 54,300 individuals for SDOH needs and facilitated 11,361 referrals to community agencies, connecting patients with vital resources such as baby needs, caregiver support, childcare, dental care, food, health insurance, housing, job search assistance, medication costs, transportation and utility bills.
The integration of Findhelp (formerly Aunt Bertha) into Marshfield Clinic Health System’s electronic health record system marked a key advancement in resource connections. This partnership helped establish a Caring for Communities platform in the electronic health record, which offered a comprehensive directory of free and reduced cost social care programs searchable by ZIP code. This integration enhanced access to resources beyond those initially screened for, including resources related to addiction treatment, behavioral health and gender-affirming services. Overall, this broadened the program’s impact and fostered stronger community collaborations.
Furthermore, a key achievement for this project was its robust recruitment, training and support of navigators, student volunteers who play a critical role in bridging health care gaps and promoting health equity. Over the course of the project 72 new navigators were trained adding to a total of 154. Through three trainings a year, navigators were educated on SDOH, and they gained skills in community resource navigation. These volunteers collectively contributed over 15,500 hours valued at nearly $500,000.
