Providence, community partners support all dimensions of health

Step into any clinic or medical facility and you’ll be asked the familiar screening questions: How are you feeling today? What brings you in? Do you have any new symptoms or concerns?

Increasingly, Providence patients also may be asked about other aspects of their health: What is your living situation today? Are you having any barriers to meeting your health care needs? Would you like assistance with housing, food or transportation?

Like the physical issues that contribute to health, these social determinants of health* – such as access to food, shelter and transportation – are fundamental to health and well-being. Many studies show that they have a larger influence on health than even medical care or behavior choices.

Across our communities, Providence is working with local partners to identify these basic social needs and to connect people with help.

Making an impact in Oregon

“As Providence, we feel strongly that social needs are a critical part of health, and that we need to address them very intentionally,” says Rachel Smith, project manager for social determinants of health in Oregon. One key response has been to bring community solutions inside clinics and hospitals.

Since 2015, Providence in Oregon has partnered with local social service agencies to staff Community Resource Desks inside seven of its clinics and hospitals, focusing on areas where social needs are highest. Impact NW, a nonprofit focused on housing stability, staffs five desks in the Portland area. At the desks, Impact NW’s team helps people with everything from accessing rental assistance and food stamps to translating letters from Medicare. “Whether you’re a patient or a neighbor, you can walk up to the desk or call, email or text – there is no wrong door,” says Smith, “and everyone is welcome.”

Since placing their teams on-site with Providence, says Impact NW program manager Diana Marquez, “We’ve been reaching more of the community and helping people who’ve never known about these services. That’s been a joy for me.”

As the commitment to addressing social needs grows, Providence has become more intentional about how it identifies these needs. Using a short, voluntary questionnaire, more than 50 Providence Medical Group clinics in the state now screen every patient for social determinants of health. More teams, including Home Health and inpatient settings, are joining the effort every day. Patients who indicate social needs are immediately introduced to the Community Resource Desk or referred to other supportive services.

“We’re trying to treat social needs like any other health need,” says Smith. “Screening for these issues is our way of demonstrating that we see the whole health of an individual.”

Breaking down barriers in Spokane, Wash.

Like the resource desks in Oregon, Providence’s Patient Navigator Program in Eastern Washington places local partners on-site in Providence facilities, where they can provide immediate, face-to-face support for social needs.

Providence Holy Family Hospital and Providence Sacred Heart Medical Center in Spokane have partnered with CHAS Health, a federally qualified health clinic, for many years. The two developed the Patient Navigator Program together in 2019 in response to a growing number of avoidable emergency department visits among CHAS patients.

The program places CHAS Health care coordinators in the emergency departments to connect personally with every CHAS patient at discharge. The coordinators chat with the patients, schedule primary care, dental and behavioral health visits if needed, and ask patients if they are experiencing any barriers to care. This open-ended question often uncovers crucial social needs that the coordinators can help resolve.

“The social determinants of health can be just as, if not more, impactful to the overall health of a patient than their medical condition,” says John Browne, CFO for CHAS Health. “Addressing them helps reduce the total cost of care, improves patient outcomes, and helps patients access the care they need to live their healthiest lives.”

As a result of these personal interactions in the EDs, 30-day return visits among CHAS patients have fallen by 70 percent as of May 2022, and primary care visits have increased substantially. In addition, hundreds of patients have gained access to food, housing, clothing and transportation – resources that often enable them to avoid hard choices between food and medication, to keep doctors’ appointments, and to follow care plans for medical issues.

“We are proud to work with CHAS Health to fundamentally improve the health and well-being of our most vulnerable community members,” says Susan Stacey, Providence chief executive for the Inland Northwest service area.

“Every person deserves the chance to feel heard, healed and supported. That is our vision of health for a better world.”

- Susan Stacey, chief executive, Providence Inland Northwest

Providence community benefit funds support the Community Resource Desks in Oregon, the Patient Navigator Program in Washington, and many other partnerships in our communities as we work together to improve health, in all its dimensions.

*Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to medical care. Addressing social needs is important for improving health and reducing longstanding disparities in health and health care.