Children's Minnesota: Community Connect

Minneapolis-based Children's Minnesota's innovation program Community Connect aims to address patients' social determinants of health needs. With multiple entry points, patients and families can enroll in the program through proactive screenings during appointments, direct clinician referrals and family self-referrals.

Community Connect comprises a team of six multicultural, multilingual resource navigators who are trained to work with families to identify and improve social factors that affect pediatric patients' health. Through the program, resource navigators help patients by designing a responsive plan of action and connecting the individuals to services that match the families' needs. Supportive resources include food access, transportation services, legal assistance, housing support, early childhood education programs and more. The resource navigators team also performs active follow-up on each case.  

Since launching in 2017 at Children's Minnesota's St. Paul Primary Care Clinic, Community Connect has expanded to Minneapolis Primary Care, Adolescent Health and two asthma clinics. The program has screened more than 17,000 patients and helped connect almost 3,100 enrollees with support resources.

The Minnesota Department of Health recently awarded Community Connect the 2019 Healthcare Home Innovation Award for the program's accomplishments. Children's Minnesota is currently piloting closed-loop referral technology from digital health software company NowPow to address food insecurity among patients and their families. The technology connects with the health system's internal food pantry, and since rolling out the pilot, Community Connect has seen a 43 percent increase in families obtaining food.

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