Moving beyond medical needs: How to successfully address social needs that impact patients and families
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1:10 - 2:00 pm Session
At Children’s Minnesota, we know that most of the things that impact a child’s health happen outside of our clinics and hospitals—it’s about where kids live, learn and play. Community Connect, a program in our Minneapolis and St. Paul Primary Care Clinics, bridges the gap between traditional health care and a child’s environment—we connect families to community resources that ensure access to things like nutritious food, safe and stable housing, legal assistance, etc. Our goal is to keep kids healthy at home and in the communities by proactively addressing health-related social needs.
This session will serve as a “how-to” guide for addressing health-related social needs. While many professionals that provide care coordination and other related services are expected to address social needs in the context of their roles, there isn’t always explicit training provided on how to do so. In this session, attendees will hear directly from Resource Navigators who have been making resource connections for over four years. We’ll focus on the three key steps in the process – identifying needs, connecting to resources, and following up to ensure successful connections. In each step we will provide practical, concrete tips and tools that participants can put into practice immediately in their day-to-day work.
Jessica Block, Manager, Community Health Programs, Children’s Minnesota (she/her)
Bio: Jessica leads work at the intersection of clinical practice and community health. Her work is closely aligned with Children’s Minnesota’s value-based care and healthy equity initiatives. Jessica currently manages a program called Community Connect. Embedded in the primary care setting, this program addresses social determinants of health as a part of clinical visits. She oversees a team of Resource Navigators who provide customized resource referrals and follow up support to families. She also builds relationships with community partners in order to reduce system barriers that impact families’ ability to access the resources they need. Jessica is passionate about advancing health equity, reducing health disparities and positively impacting the health and well-being of children and families is Minnesota.
Marayan Ibrahim, Resource Navigator, Children’s Minnesota (she/her)
Bio: Marayan helped pave the way for the Community Connect program at Children’s Minnesota. As a Resource Navigator she connects patient families with community resources and services, such as housing, income, transportation, education, legal services and food. Marayan is a Somali speaker and provides support to the Somali population at Children’s. Her work focuses on improving the socio-economic status of patients in the primary care clinic by empowering families and being the go-to person for questions from navigators and clinic staff.
Monica Rodriquez, Resource Navigator, Children’s Minnesota (she/her)
Bio: "Monica is a Spanish speaking Resource Navigator at Children’s Minnesota. As one of the pioneers of the Community Connect program, she has had the opportunity to see many families overcome social and economic disparities. Monica enjoys putting time and effort into making connections and helping people be successful. Monica is well versed in the many resources patients and families request such as food, transportation, financial assistance, housing, legal support and more. In order to help families thrive, Monica communicates with both clinical providers and staff at community based organizations in order to coordinate care. Monica is passionate about supporting the Latinx Community and enjoys working to reduce the health disparities they experience through her role."
Objectives for the session:
Conduct a conversation-based social needs screening to identify needs impacting a patient’s well-being.
Select responsive community resources based on details provided by patients/families to ensure successful connections.
Employ a variety of tactics to provide supportive follow-up as families access community resources.