The Atlanta Regional Collaborative for Health Improvement (ARCHI) recently received a grant from the National Association of County and City Health Officials and the Association of State and Territorial Health Officials (ASTHO) as a part of the Improving Social Determinants of Health – Getting Further Faster evaluation program.

The 42 selected communities have demonstrated impact in advancing health equity by addressing social determinants of health and will participate in a national retrospective evaluation to understand the impact of these efforts, and ultimately highlight successful strategies to address social determinants of health that can be adopted nationally.

“This project is a significant step toward establishing policy best practices for social determinants of health,” said ASTHO Chief Medical Officer Marcus Plescia, in a statement. “We know that addressing these determinants improves community health and saves precious resources. This research will help jurisdictions nationwide move forward with proven, evidence-based policies that create healthier communities.”

Specifically, ARCHI will assess the impact of linking clinical and community services as part of its Community Resource Hub pilots. The pilots, which are currently underway, identify and address the unmet social and economic needs of patients struggling to manage their chronic conditions. Based at Grady Health System and the Mercy Care Atlanta clinic, patients with unmanaged diabetes or hypertension are identified during a clinic visit and referred to a community health worker (CHW).

The CHW works with the patient to assess their current social and economic needs and sets goals reflective of the patient’s priorities. The CHW then identifies organizations in the Community Resource Hub Partner Network that can assist with the patient’s needs.

Through coordinated referrals, case conferences, and multiagency problem solving sessions within the partner network, the burden of navigating siloed systems (e.g., housing, transportation, workforce, food and nutrition, and benefits) are assumed by the system of care and removed from the individual. Further, intake is streamlined because the agencies in the partner network have data-sharing agreements.

Early results demonstrate that not only have patients secured housing and financial stability, their A1c scores, blood pressure, weight and body mass index are dropping. But, the evaluation of the Community Resource Hub pilot, through the national Getting Further Faster program, will assess the impact on patients’ health, change in social and economic needs, and the integration of community services into the clinical operations of the health system.

“The intention is that the result of these different evaluations will influence not only care of individual patients, but also larger systems change to both sustain support for CHWs and further integrate social services and supports into the clinical practice of health systems,” says Kathryn Lawler, executive director of ARCHI.