Connecting the Unconnected: Leveraging Community Trust to Support Sara

When the healthcare industry talks about Social Determinants of Health (SDoH), it’s often about specific buckets of SDoH needs: transportation access, language barriers, food insecurity, community support, e.g. But, in practice, individual people don’t just fit into one bucket of needs. In this ongoing blog series, we’re telling the stories of real people that we’ve helped by connecting them to multiple local Community-Based Organizations (CBOs) who are best positioned to help with each need and integrating their care with a connected plan that has visible, measurable outcomes.

Meet Sara*, a 32-year old woman who faced mental health and financial challenges that affected her and her family’s overall health and wellbeing. Her challenges included a personality disorder diagnosis, food shortfalls for her and her two children, and lack of access to a primary care provider. She also needed assistance to make her monthly rent and utility payments.

GroundGame.Health helped connect Sara to local community resources that were best positioned to make a difference. Here are the actions that took place:

  • A Care Coordinator and Sara had a three-way call with a doctor’s office so that she could set up future appointments with a mental health professional. Instead of leaving Sara to navigate the system on her own, the Care Coordinator could make sure Sara had the information she needed to schedule a therapy session. 
  • A Care Coordinator and Sara had three other three-way calls, including to:
    • A nonprofit that has a Life Needs Financial Assistance program to help with rent
    • A local church that might also be able to contribute funds for rent
    • The Salvation Army USA Midwest that could provide seasonal services for utility assistance
  • A Care Coordinator reached out to a different local Methodist church to ask about their food pantry. 
  • A Care Coordinator provided Sara with a list of primary care doctors in her area.

What were the results?

  • Food boxes for Sara’s family from the Methodist church
  • A small stipend from a nonprofit to help with rent
  • A spot on the waiting list for utility assistance from the Salvation Army
  • A successful first therapy session, with plans to continue ongoing sessions
  • An appointment scheduled with a primary care provider

Why did this approach work? 

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The organizations and people who were best positioned to help Sara were local resources: local churches, local therapy services, local branches of larger organizations. To actually access what they had to offer her, she also needed someone who could work with her directly, get to know her and her family, and be accountable for supporting them. That’s why on-the-ground Care Coordinators are crucial parts of the GroundGame.Health solution. Our Care Coordinators connect people with resources they need. They are able to do it faster, more effectively, and more efficiently because of our HITRUST certified closed loop platform. They’re especially great  at connecting people with trusted support.

The PCP appointment is only valuable if Sara has the time and ability to get there, as well as the willingness to listen to the physician’s recommendations. The food boxes are only helpful if Sara has electricity to cook in her own home. And therapy alone won’t solve the challenges of wondering if she can make her rent payments. 

Trust is the key component that helps all of these interrelated challenges. When we build trust with Community-Based Organizations who know our end goal is to help people, and build trust with those individual people who need help, we can get more done – faster, more effectively, and within a closed-loop system where we can track outcomes. This is the approach we’ve used to meet 164,613 health equity needs for people at ground level and power the flow of $19 million from Managed Care Organizations (MCOs) to CBOs. The CBOs can trust that the unrestricted funding will be steady, the MCOs can trust that the funding will improve members’ health, and people can trust that their needs are truly understood.

Want to learn more about how GroundGame.Health can support your CBO or MCO? Contact us today. 

*Name has been changed to preserve anonymity.

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