Framework
Social Needs Screening and ReferralCare Delivery Transformation FrameworkClinical Settings
Hospitals are adopting strategies to address societal factors at the community level that impact swaths of the patient population. While health care alone cannot change community circumstances, hospital partnerships with multisector community stakeholders can influence community ecosystems to…
Developing a culture and structure for interdisciplinary team-based care enables health care professionals to coordinate physical, mental and social care for their patients, especially for those with complex care needs.
Hospitals are working to make care more affordable and are enabling patients to access care where and when they need it.
Care navigators can help facilitate transitions as patients — particularly those with chronic or complex diseases — move from the acute care to home setting while remaining connected to needed outpatient services.
By fostering partnerships across providers as part of a clinically integrated network, health care organizations can better facilitate coordinated care for their patients.
Through formal and informal processes (e.g., community health needs assessments, patient and family advisory councils, community-based programs, partnerships) hospitals receive guidance on how they can better connect with individuals of all backgrounds.
Telehealth programs expand access to care so that people can conveniently receive medical advice and treatment no matter where they are located.
Innovative health care organizations are designing services to meet people where they are — in community settings such as the home, community-based clinics, schools, retail clinics, etc. This encompasses post-acute, specialty, ambulatory and primary care.
Health systems are transforming primary care to provide holistic care that closes care gaps while prioritizing prevention and managing complex health and social needs across the continuum of care in alignment with new payment models.