How trusted local entry points are key to improving community health

It is well understood today that close collaboration between health systems and social service organizations is vital for improving individual and community health. These collaborations address upstream nonclinical factors that are usually called social determinants of health.

We have also learned that it is not enough for physicians or hospitals merely to screen patients for health-threating social needs and simply refer them to social service organizations. A recent set of studies, for instance, indicates that a disappointingly high proportion of screened patients with social needs decline to obtain assistance. Reasons for declining to obtain assistance include confusion or lack of knowledge about the value of the assistance or feelings of shame or stigma about requiring help.

Dealing with this reluctance requires a person or organization to be a trusted entry point to an integrated system of services, with close collaboration between health and social service organizations and community-based organizations (CBOs). The CBO is often a critical component because it can be the trusted entry point by credentialing those who provide health and other services. Effective collaboration also requires strong “connective tissue” (the infrastructure of harmonized rules, funding, data sharing, and other operational elements) that connects institutions together as community care hubs.