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A system that facilitates closed-loop referrals between Primary Care Providers and United Way 2-1-1 Navigators. The Clinic to Community Linkage (CCL) program is a bi-directional referral and feedback system between primary care providers and United Way 2-1-1 patient navigators to connect patients with chronic diseases to community resources. This is a free resource that helps people connect to community resources to address social and self-management needs that impact health and well-being. The system is currently being leveraged to help patients served by MetroHealth, Care Alliance, University Hospitals Rainbow Babies and Children's Hospital and Neighborhood Family Practice, improve their blood pressure, and better manage their weight and asthma conditions.
Social determinants account for up to 80% of health outcomes, so making positive changes is often a matter of tackling health challenges outside the clinic. MetroHealth in Cleveland uses Epic to connect patients with hypertension to the United Way 2-1-1 HelpLink and get them resources to improve their condition. In just one month, the United Way reported that they matched referred patients to community resources over 120 times. When a patient meets clinical and demographic criteria, Epic prompts the provider to refer the patient to the United Way. With the patient’s consent, a direct message is sent to the United Way with basic clinical and contact information. Within 48 hours, a United Way specialist calls referred patients to connect them with resources from United Way’s 24,000-resource library.
