Helping families thrive through community connections

Social factors like employment status, language barriers and access to housing and healthy food can have significant impacts on our well-being. These factors, called social determinants of health, contribute to the physical health of Minnesotan families as much as or more than health care provided in a doctor’s office. Children’s Minnesota, a Minnesota health system, is working outside its walls to help families navigate these social factors through its Community Connect program.

Children’s Minnesota found that many patient families were facing barriers to getting basic needs met, which was creating strains on their health. The health system developed its innovative Community Connect program to get ahead of the social factors impacting patients by providing personalized resources and support. Care team members proactively screen families for social needs, connect them with supportive resources and engage in comprehensive follow-up to ensure those needs are continuously met. Patients are given the opportunity to share their story and have a trusted resource to rely on for support when it comes to needs surrounding food access, transportation, housing, legal concerns, education, employment and childcare, among others.

Estibaliz Quintero, a resource navigator for the Community Connect program, works to develop trusting, ongoing relationships with families through in-depth conversations, allowing her to understand their needs and provide customized resources and continuous support. “The families are just very thankful because they now know about the resources that they didn’t know about before,” she said. “And of course, it’s a cyclical relationship that we build. So the first time they will probably come for job search assistance or for information on food resources, and then they will feel more comfortable coming back for other important resources that they might need.”

Jessica, a 24-year-old single mother, was referred to Community Connect by her own mother. She has been working with Quintero to continue her education through a GED program, attain legal resources, access women’s health care and obtain speech therapy for her 4-year-old son. “Community Connect has had a great impact in my life because it helped me and my son see resources that are out there to help us and not feel that we’re being judged or scared to ask for help,” Jessica said.

Pam Ross, director of community health programs for Children’s Minnesota, believes it is the health system’s obligation to understand the big picture of what is happening in patients’ lives. “Most kids are born healthy until the environment around them can deteriorate that health. Our goal with Community Connect is to get upstream and promote stability and ongoing health and well-being,” she said. “It’s our hope through our work that we’re keeping kids well, keeping them active learners, keeping them in school and helping build a generation of successful and productive adults.”

Children’s Minnesota is also investigating the impact of the program beyond its immediate effects on patient families, exploring how it influences total cost of care and long-term health outcomes.

The Community Connect program at Children’s Minnesota reflects the importance of thinking about all the social factors that keep people healthy. “It’s our vision at Children’s Minnesota to be every family’s essential partner in raising healthier kids,” said Ross. “It’s not just sick care, it is really thinking about a well care system as well. Our community has known for a long time that what happens outside of hospital walls and clinics impacts their health. Now it’s our turn to step up and do our part.”