Check out some early lessons learned from our ROOTS (Roles Outside Of Traditional Systems) program. Here’s the link with more information: ROOTS Program Early Lessons Learned - Center for Care Innovations
We’ve also rounded up the advice of our program participants, who have spent the past year tackling upstream challenges. Whether you’re just starting out or expanding this work…
Advice for Tackling the Social Determinants of Health in Your Clinic
My favorite takeaways:
Take baby steps.
This work can begin to seem very large, and move very fast. That’s why it’s important to start small and slow.
Create an environment to experiment with screening for social needs, linking patients with resources, and building interventions. It’s important to understand if the changes work well for staff and patients before spreading it clinic-wide.
It’s not about the number of patients that you screen, but your ability to respond to their needs. Remember: EVERY patient that you serve and connect is a success.
Hear out your patients — their lived experience can fill in gaps in data.
Public health data and community surveys are helpful. But the real local experts are sitting in your clinic.
Ask your patients: Other than medical care, what do you need to be more healthy? Or what is preventing you from living a healthier life?
For its project, LifeLong Medical Care worked on food insecurity in East Oakland. By engaging patients, it soon realized that connecting its patients with food banks only addressed part of the problem. Staff uncovered that some patients struggled with transportation to even get to food banks. Others didn’t have the physical strength to carry grocery bags up the stairs to their apartments. So LifeLong began delivering boxes of fresh produce to patient homes to help address barriers identified by their patients.
Forge partnerships within your organization — not just on the outside.
Identify what resources, knowledge and connections already exist in your organization before forging new partnerships. As you enter into new partnerships, it is essential to build trust by meeting in-person and clearly understand each other’s goals and intentions.
For its ROOTS project, LAC + USC Medical Center set out to address its primary care patients’ food insecurity. While investigating various resources, it discovered that the hospital already employed a staffer from the Los Angeles Department of Public Social Services. The money had already been allocated, but she couldn’t find the right patients to enroll in CalFresh. By partnering with primary care, that social services staffer was able to quadruple the number of people she served!