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While genetics, health behavior and access to healthcare impact health, so, too, do environmental, physical and social factors. Community is working to address social determinants of health – the economic and social conditions that influence individual and group differences in health status – that lead to inequities within our communities. Continuing to evolve the role of the community health advocate, we are working to see more high-risk patients within additional defined geographic areas, ensuring a significant improvement in traditional health outcome measures. Funding will continue to provide programs to address social determinants of health and racial health disparities.
Community health advocates spend their days working with high-risk patients, individuals who have been screened for one or more unmet health-related needs — anything from interpersonal violence and emotional isolation to unstable housing and food insecurity — and connecting them to community resources to help. Prior to COVID-19, the greatest need among most patients was food. During COVID-19, housing and utilities bubbled to the top. Community health advocates help connect between 1,200 and 1,500 patients to services for specific needs each month, playing a critical role in solving for social determinants of health.
Racial inequality and social disparities have been exacerbated during the COVID-19 crisis, widening health gaps and contributing to an increased risk of infection and mortality among the African American and Latino populations. In response, and building on the successes of its Community Health Advocates program, Community Health Network is developing an accountable care neighborhood model, deploying Community health advocates within additional defined geographic areas and using all of the available health-related social need services within and outside of Community to address the most important needs identified by the community, to significantly improve traditional health outcome measures.
The Medical Legal Partnership, a collaboration between Community Health Network and Indiana Legal Services, Inc., provides free, civil legal assistance to patients in Community Health Network’s east and south regions and behavioral health patients residing in Marion County. Its individualized legal services to patients have a significant, positive impact on health-harming issues such as access to clean and safe housing, access to food, and income maintenance. These legal services provide stability to individuals and families. Patients referred to the partnership may receive help with many different civil legal matters including housing and utility, consume, and family law issues, and advance directives.
What began in March of 2017 as the east region patient assistance fund within two Community primary care offices on the east side of Indianapolis has now expanded to Community primary care offices across Central Indiana. In fact, the effort is accessible to primary care patients in all of Community’s regions, patients of MedCheck with established Community primary care physicians, and homebound patients served by the Community Care at Home program. The fund’s purpose is to provide immediate assistance to patients, helping them access basic needs like medicine, food and transportation while bridging them to longer-term solutions to best address their health-related social needs.
