Hackensack Meridian Health’s Innovative Social Determinants of Health Program, Healthy Connections, Hits Major Milestone with One Million Referrals

Hackensack Meridian Health facilitated 1 million referrals to social service agencies to provide assistance beyond traditional healthcare for patients throughout NJ

Hackensack Meridian Health, New Jersey’s largest and most comprehensive health care network, today announced that its groundbreaking social determinants of health program, Healthy Connections, reached a significant milestone just one year after it was launched, providing 1 million referrals for support beyond traditional healthcare.

The network is a national leader in a new approach to healthcare that includes addressing non-medical factors that have a great impact on health including access to healthy food and safe housing, transportation, factors that are known as the social determinants of health.

"At Hackensack Meridian Health, promoting health equity and human dignity to improve the health of our communities is a strategic priority,” said Robert C. Garrett, FACHE, CEO of Hackensack Meridian Health. "This comprehensive approach to healthcare is truly the way forward to improve health outcomes in the nation and enhance the quality of life in the communities we are privileged to serve."

Through this innovative program and a unique partnership with Unite Us, Hackensack Meridian Health launched Healthy Connections in June 2021, becoming the first healthcare system to assess total patient health, including non-medical needs, at all points of entry. Team members quickly identified five issue areas that were a priority for patients: food, housing, transportation, caregiver support, mental health/substance abuse treatment.

Ruth Wiseman of Teaneck, NJ was overwhelmed with a full-time job and caring for her 94-year-old mother Rita Kuhn, who had advanced dementia. Community Health Worker Lisette Morales obtained a wheelchair for Ms. Kuhn, helped her daughter hire a new home health aide, scheduled medical appointments and ultimately arranged hospice care for Ms. Kuhn. She worked with the family for six months until Ms. Kuhn died in June.

When Ms. Morales reached out, "I felt like a prayer had been answered," Ms. Wiseman said. "I had for weeks been thinking I’m not going to be able to manage everything. This service is such a gift. There is somebody out there who understands and has the resources at hand to connect you with what you need."

In June 2021, all health care settings across the network began providing consistent screening. Today, the network screens up to 5,000 patients daily. If a need is discovered during the screening process, the patient is referred to community partner organizations for assistance.

To date, more than 370,000 patients have been screened and more than 1.25 million referrals for services have been completed.

"Utilizing technology and an innovative network-wide strategy to address social determinants of health, Hackensack Meridian Health is reaching more patients than ever before,” said Patrick R. Young, president of Population Health for Hackensack Meridian Health. "We are incredibly proud of the groundbreaking work we are doing to connect patients with the necessary support services they need. We know that by focusing on key issues, we can make a real difference in our patients' lives and build healthier communities.”

Research shows that health outcomes are driven by many factors beyond healthcare, including socio-economic factors, health behaviors and underlying genetics.

Personalized referrals are provided to patients in 152 languages by email, print, or text message. The Unite Us platform has been integrated into the network’s electronic health record system and referrals are added to a patient’s record. This critical information gives providers an understanding of all aspects of a patient’s life as part of the continuum of care.

"Hackensack Meridian Health is committed to transforming healthcare by creating life-changing programs like Healthy Connections, which will help improve outcomes, save lives and make healthcare more accessible,” said Nicole Harris-Hollingsworth, EdD, MCHES, vice president of Social Determinants of Health at Hackensack Meridian Health. "Over the last year, we have impacted hundreds of thousands of lives with one million referrals, and I am so excited about what the future holds for this outstanding program.”

Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages. During the COVID-19 pandemic, communities of color were three times more likely to contract the virus compared to their white counterparts and twice as likely to die.

Another essential component of the program’s success is the hiring of 24 community health workers who have a deep understanding of the resources in the area. They connect patients with services they may not even know exist.

Lisette Morales is deeply satisfied by her connections with clients, including Ms. Wiseman and her family. "My job is to help people at the social level. Sometimes health care is not as easy as going to the doctor and getting prescriptions. There are so many other factors people have to deal with today. I’m kind of like a personal assistant who can help people stay on track and reduce stress."

"By bringing together health care and community-based partnerships, we are improving health outcomes one patient at a time by connecting them with the resources they need from housing assistance to counseling and so much more,” said Dan Brillman, Co-Founder and Chief Executive Officer, Unite Us. "We are dedicated to improving the health and well-being of communities, and Hackensack Meridian Health is the perfect partner to help us do that across the State of New Jersey.”

In addition to Healthy Connections, the Hackensack Meridian School of Medicine is training future physicians to consider all aspects of a patient's life, including non-medical factors. The Human Dimension curriculum embraces service-learning experiences and an integrated curriculum, training students to understand the Social Determinants of Health.

Throughout the entirety of their medical education, students meet in pairs with people in underserved areas to understand how socio-economic factors impact healthcare. Even before they write their first prescriptions as physicians, they understand how safe housing and access to nutritious food and transportation can greatly impact health.

"The more we can work collaboratively with our outstanding community partners and social service agencies, the healthier our communities will be,” said Mr. Garrett. "Together we are providing a more holistic and equitable approach to health, ensuring our patients and their families have the vital resources they need to achieve their best health.”