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Community Resource Coordination

Understanding Social Determinants of Health

Ascension Saint Agnes Community Health Partners CTO supports practices in implementing effective screening workflows for social determinants of health. We understand that factors such as access to healthcare, safe housing, nutritious food, transportation, and social support greatly influence an individual's health outcomes. Our interdisciplinary case management team connects patients to our network of community resources to empower individuals to overcome barriers and improve their overall quality of life. Depending on the patient's needs varying levels of community resource coordination are available.

Examples of services provided include:

  • Food Access Services: We connect individuals with food access programs including food pantries, community gardens, farmers markets, and government assistance programs. We also provide condition specific healthy eating habits and budgeting to promote food security and improve nutrition outcomes.
  • Housing Assistance: We provide linkage to affordable and safe housing options, rental assistance programs, and housing counseling services to address housing instability and homelessness.
  • Transportation Services: We help individuals access reliable transportation options, such as public transit, ride-sharing services, or community transportation programs, to ensure they can access essential services and appointments.
  • Financial Assistance: We help individuals navigate available financial assistance programs, such as income support, benefits enrollment, and financial counseling, to alleviate financial burdens and promote economic stability.
  • Behavioral Health Navigation: Our team aids individuals who are seeking mental health or substance use treatment by helping them navigate complex healthcare systems and access necessary care.
  • Legal Aid and Advocacy: We collaborate with legal aid organizations to provide individuals with access to legal assistance, advocacy services, and resources to address legal issues that may directly impact their health and well-being.
  • Social Support Networks: We facilitate connections to community groups, support networks, and peer-to-peer programs that foster social engagement, combat isolation, and promote mental well-being.

Ascension Saint Agnes Community Health Partners CTO is committed to person-centered care, recognizing the importance of addressing social determinants of health to achieve optimal health outcomes. Our CTO can also advise on innovative ways to leverage HEART (Health Equity Advancement Resource and Transformation Payment) funding to improve outcomes for beneficiaries with complex medical and social needs.

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