Social determinants of health (SDOH) encompass non-medical factors influencing health outcomes, reflecting conditions of daily life. Care Management plays a crucial role in addressing patients' social needs through comprehensive questioning and by understanding their current situation, we facilitate connections to essential services and resources. With the integration of the information on our platform, we refer it to Community Health Workers (CHWs) to ensure effective support. Subsequent screenings every few months demonstrate our proactive approach to ongoing support to our patients, ensuring needs to be continually met for overall well-being.

Social determinants of health play a crucial role in engaging with the parents of our patients. At the core of our mission, we ensure the completion of survey forms and gather valuable feedback; we utilize a variety of communication methods including calls, text message, and voice mails. Through our interactions, we go beyond merely collecting feedback; as it serves a broader purpose of assessing whether these families have access to essential needs such as food, clothing, and other basic necessities. This approach of ours underscores our commitment to not only improving our services based on their insights but also ensuring the well-being of the families we serve.

By maintaining regular and compassionate communication, we strive to create a supportive environment where parents feel comfortable sharing their opinions and concerns. This approach allows us to enhance our services and identify and address any potential gaps in support for these families. Ultimately contributing to their overall well-being and satisfaction with our care.

Upon identifying needs such as food or clothing, our program initiates a referral call to connect our patients with community-based organizations capable of providing assistance. Our process ensures individuals receive timely support from specialized services tailored to their specific needs. By facilitating these connections, we aim to enhance the overall well-being and quality of life for our patients, addressing both their medical requirements and broader social and economic circumstances. Our commitment to proactive referrals and collaboration with community resources underscores our dedication to comprehensive patient care, ensuring individuals receive the holistic support necessary to thrive beyond their healthcare needs.

After connecting patients with community-based organizations, we do a post-evaluation contact to ensure they received the necessary assistance. This proactive step from us not only verifies the successful engagement of external support but also underscores our commitment to comprehensive patient care. By confirming the accessibility and effectiveness of these resources, we aim to enhance patient outcomes and satisfaction, fostering a stronger network of support within our community. This practice reflects our dedication to delivering healthcare solutions that meet the diverse needs of our patients.

Following the completion of our patient's screening, we initiate regular outreach every few months to reassess and address our evolving patient needs. Our approach ensures that we remain responsive to changes in patient requirements over time. By maintaining regular contact, we provide ongoing support tailored to each patient's current circumstances. Our commitment to periodic follow-ups underscores our dedication to delivering personalized care that adapts to the dynamic nature of individual healthcare needs. Through these efforts, we strive to uphold the highest standards of patient-centered care, facilitating optimal health outcomes and ensuring comprehensive support for our patients.