At a Glance
This project, Social Service Redesign, led by Sixteenth Street Community Health Center (SSCHC) aims to improve health outcomes by reducing housing insecurity. SSCHC is Milwaukee’s largest federally qualified health center and has been addressing the health needs of economically disadvantaged individuals, many of whom face housing issues and homelessness. In its first two years, the project established an AmeriCorps program with 13 members, including four resource navigators. Resource navigators and volunteers have contributed to a 44.5 percent increase in completed, totaling over 8,700 patients. Housing needs have persisted as a priority, leading to the implementation of an internal housing protocol.
The Challenge
Sixteenth Street Community Health Centers (SSCHC), Milwaukee’s largest federally qualified health center, has been effectively serving a population of economically disadvantaged individuals, with a substantial proportion living in poverty. A large number of patients have reported housing issues, and a portion have experienced homelessness. SSCHC anticipates serving over 50,000 patients annually, underscoring the need to integrate social services into clinical care delivery. Growing evidence has emphasized the detrimental impact of unmet social needs on health outcomes and health care utilization and integrating nonmedical social services with medical services has been shown to improve outcomes, achieve cost savings and promote equity in health care.
Project Goals
The overarching goal of this project is to improve health outcomes by reducing housing insecurity, challenging the traditional health narrative and transforming service delivery systems while strengthening partnerships. In the short term, SSCHC aims to engage stakeholders, understand the root causes of housing instability and raise patient awareness of available resources. In the intermediate term, the project plans to integrate social needs programming into clinical care, creating sustainable interventions connecting patients with community-based resources, particularly for housing insecurity. Social Service Redesign’s comprehensive approach involves a detailed environmental scan to guide stakeholder mobilization, prioritization of actions and strategy implementation.
Progress Update
In its first two years, Social Service Redesign made significant progress in its efforts to transition to a tiered model of service provision within the SSCHC Social Service Department. In September 2020, SSCHC established its own AmeriCorps Program supporting 13 AmeriCorps members, four of which were resource navigators. Together, the resource navigators and 27 Volunteer Coordination Program volunteers screened patients for social needs. The screening process itself grew, with a 44.5 percent increase in the number of screens completed in 202 compared to the previous year. To date, more than 8,700 patients have been screened. Housing remained a top need identified by patients and SSCHC implemented an internal housing protocol to address the issue. This protocol followed patients for three months following their initial screen and referral to housing resources.