PolicyLab

COVID-19 has hit families and communities not just with a medical crisis, but a social crisis as well. As we all sheltered in place, many families have been grappling with critical issues such as lack of child care, job loss and reduced hours, less access to free school meals and housing insecurity. While social determinants of health and social risk services in health care systems are not new concepts, the pandemic, new accountable care models and, in some cases, state requirements have pushed health care systems to increasingly focus on finding new ways to build in these services and partner with community-based agencies to address their patients’ social needs.

With this changing landscape, we have had the opportunity to work with leaders and champions across Children’s Hospital of Philadelphia (CHOP)—including the Division of Social Work, the Population Health Innovation team, Safe Place, the Healthier Together Initiative, the primary care network, information services and many others—to strategize ways to expand on and standardize care for health-related social needs across the institution.

In particular, our group was interested in how to leverage technology to provide support in not just one area of the hospital, but across the institution to help patients connect with community services. As part of this work, a grant from the Verizon Foundation allowed us to develop and test the use of a community resource mapping platform, which we were able to quickly build out and offer as a support tool in response to the COVID-19 pandemic.

Building Community Resource Connects: A community resource mapping database

Last year, we began working with Aunt Bertha, a public benefit corporation platform, to develop a community resource map that we call Community Resource Connects. There are many ways that health care systems can think about building and expanding on services to directly address social needs, but often just finding and connecting patients with existing services in the community is a challenge. At a minimum, a resource map is a tool that both hospital staff and families/individuals can use to identify local community services and programs by ZIP code. The ZIP code search helps individuals identify programs by type of need that are close to home.

The goal of this tool is not to replace the person-to-person support that is often critical to connecting families to services, but rather to provide a nimble, centralized tool that can help both teams and individuals find the right resource, in the right place, at the right time. Our team has spent the last year compiling and organizing resources on Community Resource Connects with invaluable help from social workers, parents and two pilot sites (inpatient and primary care).

Aunt Bertha’s platform offers features that make the site easy to navigate and useful for its users, including the ability to:

• Search for local, child/family-focused community resources by ZIP code, like food pantries and meal sites, utilities support, housing support and child care
• Accommodate searches outside of Philadelphia, including the surrounding counties, Southern New Jersey and Delaware
• Allow clinicians and other staff to text/email program links directly to families/individuals
• Translate the site into multiple languages
• Create customized handouts that can be easily translated, printed and emailed to families

CHOP staff have full access to the website, including through the electronic health record. The resource map also has the potential to support direct referral mechanisms—i.e., to make referrals to community-based services for yourself or others directly from the site, and also receive notifications as to whether or not the person referred connected with that service. While this functionality is widely discussed across platforms, to our knowledge it is largely untested and is something we hope to build into Community Resource Connects in collaboration with community-based partners in the next phase of our work.

Adjusting to the COVID-19 Crisis

Leading up to the COVID-19 crisis, the use of our website was still limited across CHOP. It became very clear as families sheltered in place and businesses closed their doors that the level of community and social need would be extraordinary. Our team quickly worked with Aunt Bertha to add a number of COVID-specific features to the site, including a list of COVID-19 resources on the homepage, alerts to direct families to county-specific COVID-19 information, and a “COVID-19 Response Program” tag to ensure resources specific to the pandemic would be easy to find.

We have also partnered with the Coalition Against Hunger and Philabundance to maintain an updated list of food pantries and meal sites in the greater Philadelphia area, a small demonstration of the value of health care systems and community-based organizations partnering together to share information.

Between January and March 15 of this year, we saw about 250 weekly searches on the site. Between March 16 and May 10, that number jumped to an average of 2,200 weekly searches, peaking at more than 3,800 searches in the last week of April. Since early March, searches for food resources (“food pantries,” “free meals” and “help pay for food”) have accounted for nearly 60% of the searches on the site, followed by help with utilities (16%), housing (5%), child care (4%) and clothing/baby supplies (4%).

This high number of searches is a demonstration of the incredible level of need, and the increased demand our community-based partners are facing. This type of data also holds the potential to help us better understand the highest priority needs. Of course, families’ needs are never as simple as one issue, but knowing what our community is searching on the site can help us understand where future support and funding could be most needed.

Looking beyond the COVID-19 crisis

We expect the impact on families’ financial hardship to last far beyond the pandemic itself, and anticipate many residual effects on family’s basic needs such as food, housing and employment support. Although the resource map is only one tool, we hope it can help providers and families identify the right resource at the right time.

As community-based organizations work around the clock to maintain critical support services for families and communities, CHOP has started to work with Penn Medicine, the Health Federation, Jefferson Hospital, the City of Philadelphia Department of Public Health and other health partners in Philadelphia to coordinate our respective resource mapping efforts and work toward a collaborative model across our region.

One of the many lessons we have learned in this process is that the website will constantly be a work in progress—with the ever-changing landscape of community resources, the fast-developing functionality of electronic health records, and the emerging research around the best ways to refer patients to services, our goal is to leverage technology to provide one key ingredient in the complex system that is needed to truly address families’ needs.

Leigh Wilson-Hall, MSW, LSW, is a former senior improvement advisor for the Population Health Innovation Team at Children’s Hospital of Philadelphia.

Bianca Constant, MSW, LSW, is a former community implementation specialist at Children's Hospital of Philadelphia.