Monument Health has implemented a data-driven, patient-centered approach to address substance use disorders and social determinants of health, issuing monthly reports that track key outcomes such as housing placements, treatment assessments and successful transitions into care programs. These metrics show consistent improvement over time and correlate with a notable boost in staff morale, driven by visible progress in patient wellbeing and reduced emergency room and hospital usage. The organization has launched an innovative inpatient addiction medicine program coupled with an ambulatory patient-centered medical home to ensure seamless care across settings. Community health workers and clinical providers lead this innovative initiative, creating continuity between inpatient and outpatient services while addressing the root causes of patients’ health challenges.
