Closing Gaps in Care with Community Resources

By Bonne Farberow, MSN, RN-BC, CCRP, Population Health Strategic Executive; a HIMSS Innovation Committee Member

There is not just one priority obstacle to addressing the social determinants of health to help integrate underserved populations into the healthcare system. There are multiple.

We as healthcare providers are addressing populations living under bridges, in the remote forests, under boardwalks on the coasts, in the mountains and in the deserts. There are homeless individuals across the country in cities and in rural areas. There are patients that have a home, but are unable to obtain food that is healthy and within their budget. There are patients that cannot afford medications to treat their diseases. Healthcare cannot do it alone, we must work within our communities to connect individuals in need to community resources.

I have been involved for several years with a community resource in making thousands of peanut butter and jelly sandwiches and large snack bags for the homeless in my area living in the woods. While this does not address their healthcare needs or even their daily need for healthy meals, it’s a positive step. In this HIMSS Innovation that Sticks podcast episode, Mary Jane Konstantin, senior vice president and head of business at HGS Population Health Management Solutions, shares that social determinants of health obstacles include housing problems, transportation access, food shortages and language barriers.

Identifying Gaps in Care

Before we can connect those in need to community resources, we first have to identify who is in need. From a healthcare perspective, wellness screenings are one way patients encountering challenges may be identified. During an assessment, there are key areas providers should take note of:

  1. Does the patient have good overall hygiene? Clean clothes, hair, teeth, nails?
  2. Are they under or over the normal range for their body mass index? Has the patient eaten recently? Do they have easy access to food?
  3. Is a family member or friend with them?
  4. How did the patient get to the office? Any issues with transportation?
  5. Do they have an occupation and if so, are there potential health hazards or risks involved?

Based off the assessment, it may become clear the patient is in need of support services. Outreach by your health system to help patients address challenges and close the gaps in the social determinants of health can include all aspects of the community from local organizations, religious networks, healthcare clinics and shelters.

Identifying Community Resources to Close Gaps in Care

As a health system, developing a network within your community is critical. With a little digging, you’ll likely find support systems that you are not aware of. A good start is to identify a staff member who can help with finding community resources, including:

  1. Health insurance resources
  2. Housing support
  3. Meal assistance
  4. Medicaid application assistance
  5. Medication help
  6. Social services
  7. Transportation options

If the patient does not qualify for insurance there are Federally Qualified Health Centers that frequently have sliding scales for medical and dental care. Mobile health units are another great resource for underserved or rural populations. These provide wellness screenings and tests, vaccinations and even mammograms and dental care, often at no cost.

Asking the right questions and having resources ready and available to ensure patients get the help they need is all part of the evolving priority of managing our patients through the ecosystem of population health.

The views and opinions expressed in this content or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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