Research shows that when patients receive the social resources they need, hospital admissions can be reduced and overall health can be improved. By documenting and tracking a patient’s social health journey in addition to their clinical health, gaps in care can be mitigated.
The CCN began in 2016 in Nevada with referrals to community resources within the hospital, using an existing technology. In late 2017, the CCN began making referrals to a dozen external community organizations in Santa Cruz, California, and saw significant benefits of bringing social workers and community program leaders together to network and understand the resources available.
Now, the CCN model has expanded to include more community-based organizations (CBOs), other stakeholders, and enhanced mechanisms for sustainability to rightly center health in the communities themselves.