By JULIE MINDA
Before Providence St. Joseph Health's Oregon region began inviting social service agencies to staff community resource desks in some of its clinics about three years ago, Dr. Elizabeth O'Neill says she often found herself at a loss as to how to address the pressing socioeconomic needs of patients.
Providence St. Joseph Health's Oregon region has set up community resource desks in six of its clinics. This one is at its Providence Tanasbourne Health Center in Hillsboro, Ore. Specialist Yazmin Navarro, seen in the background, staffs this desk.
"If I don't screen for the social determinants that affect health, I know I'm not getting the full picture," says O'Neill, who is a family medicine physician at Providence Medical Group Gateway in east Portland, Ore. However, "if I ask, but don't have the resources to help, it's impractical. I'm trained as a physician, not a social worker."
Now, with community organizations staffing resource desks at six Providence Medical Group clinics and other Providence facilities in and around Portland where economic need is high, patients and other community members can get practical one-on-one assistance navigating and accessing social services.
"It's strengthened the relationships we have with patients," O'Neill says. "It's hard for me to imagine practicing medicine now without screening for the social determinants of health and referring people who need help to the desk."
Brian Olson, right, senior community program and service coordinator at St. Joseph Health's community resource center in Eureka, Calif., assists a client trying to access social services.
O'Neill notes that with knowledgeable social service navigators helping patients get assistance with social service needs, her clinic's advanced practice staff have been freed to work to the top of their licenses and focus on medical care.
As described in an October 2017 National Academy of Medicine discussion paper, "medical care is estimated to account for only 10 to 20 percent of the modifiable contributors to healthy outcomes for a population." The other 80 to 90 percent — factors called social determinants of health — include health-related behaviors, socioeconomic factors, and environmental factors.
In its 2018 to 2022 integrated strategic and financial plan, Providence St. Joseph recognizes the importance of social determinants of health to a population's well-being and longevity. To advance physical, spiritual and emotional health in its communities, Providence St. Joseph has encouraged its six regions to pursue partnerships and market-specific approaches to address social determinants that correlate with poor chronic disease management and poor health outcomes.
Live aid
The help desks at the Portland-area primary care clinics and other facilities are staffed weekdays by representatives of nonprofit community organizations who speak both English and Spanish. (Translation services can be arranged for people who speak another primary language.)
Help desk staff work with individuals and families to identify and prioritize needs and help them fill out applications for public programs and other community resources. They follow up to make sure the client is able to secure services, explains Yazmin Navarro, an employee of Impact NW who staffs one of the desks.
Michael Finamore, a CARE Network nurse, performs a medication review and fills his patient's medication organizer. The patient had been discharged to a medical respite room at Healing Ring in Eureka, Calif. St. Joseph Health of Humboldt County rents five beds at this clean and sober house for homeless patients.
Navarro has helped people access housing aid, health insurance, utility assistance, transportation help, supplemental nutrition benefits, food pantries, dental care, and help with job searches. She says most of the clients she advises initially are unaware that social services and health resources are available to them.
Nurse Pam Mariea-Nason leads the community health division with Shelley Yoder, a social worker and the program manager of the community resource desks in Oregon. Mariea-Nason says the social service navigation responds to issues surfaced in community health needs assessments — including housing, food and transportation insecurity — by connecting people directly with service providers who can provide practical help. Yoder says this is essential because "health care can't solve these issues by ourselves. This needs to be a community-wide solution."
Northern California
Providence St. Joseph's Northern California region, which continues to operate under the name St. Joseph Health, is taking a two-pronged approach to the socioeconomic needs of its patients. A team assists vulnerable patients who are transitioning from St. Joseph Health hospitals to home with health and social services management through its CARE Network program. And in several communities the health system operates outreach centers to bring together social service providers in one convenient location.
Donna McQueen, center, a complex care nurse with the CARE Network in Humboldt County, Calif., helps her patient move to transitional housing. McQueen provides care coordination, navigation and support to patients who are using the emergency department frequently.
The CARE Network team may include registered nurses, social workers and health coaches — St. Joseph Health has tailored its teams to meet the particular needs of the patient population in each of its communities in Northern California. For patients with pressing socioeconomic needs, the CARE Network provides intensive navigation for accessing medical respite, other housing assistance, food aid, transportation and mental health services.
Stacey Stirling, a community benefit operations manager for St. Joseph Health in Sonoma County, located in San Francisco's North Bay area, said patients in the CARE Network tend to have a high level of need, but a low level of trust in the institutions that could help them. Being present in their community, building relationships with them and helping them access services has increased the level of trust, she says.
Shanahan
Nearly 300 miles north of San Francisco, in Humboldt County, St. Joseph Health has opened five resource centers where staff and volunteers from community partner organizations offer social services, classes, support groups and other outreach to community members. People who visit the centers can get help with accessing food, housing, transportation, job training, family counseling, clothing and hygiene items.
Martha Shanahan, manager for community health investment for St. Joseph Health in Humboldt County, says trust-building and relationships are key to the success of the community resource centers. "And that's what our staff do. And then we can funnel people to appropriate care."
Dan Schurman, community partnership manager for St. Joseph Health in Sonoma County, the heart of California's wine country, said there are many individuals and families who struggle with homelessness there. Transportation also can be a big barrier for people with limited resources in Sonoma and Humboldt counties.
St. Joseph Health taps community benefit funds to provide transportation assistance to and from medical and social service appointments. The aid comes in the form of bus passes, taxi rides and gas cards, he said.
Spokane community court tackles socioeconomic needs
As part of its efforts to get at unmet socioeconomic need in its community, Providence Health Care of Spokane, Wash., provides financial and other support that allows a community court to offer alternatives to jail time to people who commit nonviolent misdemeanors. The court incentivizes offenders to seek social services and other aid to address the problems that may be at the root of their offenses.
Overseen by the Spokane City Municipal Court, the court convenes every Monday in meeting rooms at a branch of the Spokane Public Library; another session is held in a community center. Representatives of social service providers are present at both locations during the court sessions to help with access to disability assistance, job training, education, clothing, housing, food, transportation, trauma therapy, mental health care, medical care and other aid.
Before going in front of a judge, people with qualifying charges — offenses like trespassing, panhandling and public intoxication — meet with a prosecutor and public defender at the community court. During the sessions, the prosecutor and public defender move quickly from individual to individual, assessing their cases and in many instances negotiating agreements specifying defined steps the offender will take to confront his or her challenges. If the person completes the steps and graduates, the court will drop the charges.
Established in 2013 — and modeled after similar courts elsewhere in the U.S. — the court has graduated more than 700 people between its two locations.
Part of Providence St. Joseph Health, Providence Health Care of Spokane supports the community court as one way to help reduce what it says is unnecessary reliance on hospital resources by some community members. A hospital staff member of Spokane's Providence Sacred Heart Medical Center attends the court to help identify people seeking help there who are high users of hospital services. Her goal is to work with the individuals, the court and community organizations at the court to holistically address the individuals' concerns.
Providence Health Care has provided $21,000 in funding for the court, to fill funding gaps, and is considering additional contributions. And Sara Clements-Sampson, manager of community health programs for Providence Health & Services, sits on the community court's board.
— JULIE MINDA