New initiative connects hospitals with community groups

HARTFORD — Social determinants of health — the conditions in which people grow, work, and age — shape people’s lives. And research shows they may have a bigger impact on a person’s health than almost anything else.

That’s why the Connecticut Hospital Association partnered with Unite Us to provide the new software that enables realtime coordination between health care and community services.

The initiative, which is dubbed Unite Connecticut, launched three weeks ago at Griffin Hospital in Derby and Waterbury Hospital. The initiative will be rolled out through 2021 to all 27 acutecare hospitals in the state.

Liz Beaudin, senior director of population health for CHA, said 60 percent of what affects someone’s health has to do with social and behavioral issues.

“We recognize to be successful with medical care we need to be partnering more closely with patients and attending more closely to social needs,” she said.

Essentially, the software platform allows medical providers to refer patients to community organizations where they can receive help with food, housing, transportation, and employment.

Monica Oris, the director of population health at Griffin Hospital, said in the first few weeks they have referred about 15 people for services. Oris said the referrals varied: some were for food assistance, mostly meals on wheels for the elderly, and some to food pantries, and others were for transportation.

“We find that a lot of people either have diabetes and prediabetes, are not eating properly and their blood sugar spikes or drops and brings them to the hospital many times,” Oris said.

Leslie Swiderski, program supervisor for the Waterbury Health Access Program, said they are still in the process of establishing relationships with their local community partners, but a previous diabetes management program through the Chase Outpatient Center and Unite Us referred more than 118 people for services. That program lasted a year and helped refer at least 17 people for housing, 33 for transportation and 37 for food assistance.

“How is diabetes going to be in control if you don’t eat healthy?” Swiderski said.

Swiderski said medical providers often encounter people in vulnerable situations like the emergency room when they are at their worst. She said they develop deep connections with individuals and want to see them succeed at being healthy.

Swiderski and Oris both said the best part about the Unite Us software program is that it allows them to see if patients follow through and access those services through the community partner.

“Following up with the service, that’s the one piece of the puzzle that was missing from the work we were doing,” Oris said.

John Brady, CHA’s chief finance officer, said that’s the beauty of the Unite Us platform.

He said organizations are dedicated to doing this work every day in medical settings, but the process is manual and resource and time intensive. He said the technology cuts down on the amount of time it takes to track down the information about community providers and it gives medical professionals information about a patient’s followup.

Unite Connecticut will also include a resource database that leverages the work of 211 Connecticut, a program of the United

Way of Connecticut, as part of the statewide network.

“Our aim is to be inclusive and stop perpetuating silos of information and silos of care for individuals,” Brady said.

Beaudin said medical providers like the system because it cuts down on administrative work.

“The main goal is to really provide collaborative health care and keep people healthy,” Beaudin said.