Inverting the burden of navigating health and social services with community resource hubs: a metro-wide patient-centered social needs referral network - in the metro atlanta area, residents…

Inverting the burden of navigating health and social services with community resource hubs: a metro-wide patient-centered social needs referral network - in the metro atlanta area, residents managing chronic conditions are faced with many barriers to optimal health and well-being. Inadequate health and academic education and access to quality health care services has created disparate conditions among metro atlanta residents. Georgia was ranked among the 13TH highest mortality rate due to hypertension, with 56% of non-hispanic black adults in georgia living with high blood pressure. (centers for disease control and prevention, 2022; georgia department of public health, 2023) for many managing hypertension, the condition is compounded by food insecurity and hunger. In georgia, 1 in 9 (10.7%) people who are food insecure. (atlanta community food bank, 2024) these conditions are exacerbated by disconnected medical and social service systems that do not center the individual. Unable to navigate the system with ease, residents are forced into a cycle of poor health and the system is burdened with increased emergency room utilization, and underutilized preventative health and social services. The atlanta regional collaborative for health improvement (archi) proposes to address this problem with the following project: inverting the burden of navigating health and social services with community resource hub: a metro-wide patient-centered social needs referral network. The community resource hub (CRH) places the patient with a community health worker at the center of care, embeds the CHW in a local health system focused on a specific marginalized community, and establishes a real-time closed-loop loop referral network with community-based organizations to optimize community linkages to address social drivers of health. Our goal is to (1) improve hypertension control for high-need patients and (2) address food insecurity / hunger and other social determinants of health through four different CRH sites each year, supporting at least 500 previously underserved patients per year. By centering the patient and providing increased access to health care, health education and social services, and sharing data among service and medical organizations, this project will improve monitoring to demonstrate system-level outcomes as well as process and impact improvements in hypertension control and food insecurity. Our learnings and best practices will be disseminated to partners, key stakeholders, the community, and those living with chronic conditions to foster medical and social service systems that center the individual and improve preventative health services and decreases disparate conditions among black residents.