This project, Social Service Redesign, led by Sixteenth Street Community Health Center (SSCHC) aimed 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.
The Challenge
Sixteenth Street Community Health Centers (SSCHC), serving Milwaukee’s south side, has faced a significant challenge in addressing the social determinants of health (SDOH) impacting the Latino patient population. The region faces high rates of poverty, housing insecurity, language barriers and a health professional shortage. In 2017, 86 percent of SSCHC patients were Hispanic, 72 percent were best served in a language other than English and 69 percent lived in poverty. Housing instability emerged as a pressing issue, with social workers documenting over 1,100 instances of housing-related concerns in one year.
Project Goals
The overarching goal of this project was to improve health outcomes of patients by reducing housing insecurity through data-informed care. Within five years, SSCHC aimed to embed social needs programming into clinical care to create sustainable interventions that connect patients with community-based housing and support services. Key goals included:
Increase SSCHC staff’s understanding of availability of and access to community resources;
Hire and train patient navigators to help individuals access and navigate essential social services;
Implement the PREPARE screening tool to identify social needs and guide interventions;
Collaborate with cross-sector partners and leveraging community leadership to advocate for systems level and policy change; and
Use evaluation data to refine strategies and expand interventions to other social determinants of health (SDOH).
Results
SSCHC completed 22,361 social determinants of health (SDOH) screenings, with 11,025 screenings conducted in 2024 alone – far surpassing the initial goal of 6,400. These screenings identified that 67 percent of patients had one or more social needs, leading to over 2,300 referrals to Social Services and more than 24,000 resource handouts provided directly to patients. SDOH screening became a standard part of care across five SSCHC clinic locations and multiple specialties, including primary care, urgent care, midwifery and behavioral health. Patients received tailored, respectful care that addressed barriers to wellness. While not all patient needs could be met immediately, all who indicated a need were offered assistance.
The team successfully implemented a Tiered Services Model that leveraged a multidisciplinary team, including SDOH interns, intake coordinators, patient navigators and social workers. An SDOH internship program trained students to deliver social services support, extending SSCHC’s reach in community health. In addition, the Center for Urban Population Health (CUPH) supported project evaluation and data analysis. CUPH trained 10 students, contributing 2,030 hours to insights into housing insecurity and interdepartmental collaboration.
