There is overwhelming evidence about the effects that social and economic factors, like poverty, have on health and development. Recent reports reveal significant health inequities for low-income people in Madison and the surrounding areas. Clearly, factors like access to affordable, healthy food and safe transportation have a substantial impact on health outcomes.
Fortunately, some hospitals and clinics have started programs to screen for basic social and economic needs, and they are proving effective in helping providers identify patients with significant risk of chronic illness or hospitalization. Though this strategy is useful for patients, many providers feel limited to implement it in the absence of concrete processes for follow-up.
In response, a subset of communities around the U.S. have begun experimenting with broader clinic-based navigation, many along the lines of the Health Leads model. Initial data from these and other programs suggest promising outcomes for patients, such as improved health of sickle cell and asthma patients, decreased stress and improved well-being among participating families. Equally important, these programs have lead to improved satisfaction for healthcare staff and increased capacity to address root systemic health issues.
Community Connections, a project of the ACTIVATE Initiative, brings together collaborators from the University of Wisconsin, the Madison community, and health systems to implement a Resource Navigator Program in three clinics across Dane County, beginning with a pilot program at Wingra Family Medical Center. It builds upon the progress made in the first year of a pilot grant, including increasing clinic-based screening services in order to identify unmet basic needs such as food security, transportation, child care, and housing. Undergraduate students will be trained as navigators and work directly with families to link them with key community resources to address crucial needs. The resource navigators will provide regular follow-up with patients to help assess additional needs, refine plans, and ensure families access resources they need to be healthy.
Expected outcomes from the clinical navigation program include: (1) a model that demonstrates improved health outcomes, increased health equity, and better patient experiences; (2) health care provider and system support for investing in “upstream” interventions to improve health equity; (3) transformational educational experiences for students; (4) a plan for program sustainability and expansion, including a Resource Navigation Toolkit; and (5) powerful local data about how to promote health equity by accessing health and community resources and partnering with communities disproportionately affected by persistent barriers to optimal health.
For more information on the Community Connections resource navigation project, please contact Lane Hanson, Child Advocacy Coordinator, at email@example.com.