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Addressing Our Patient's Social Needs

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Social factors have a huge impact on health.

Many community members have a hard time living their healthiest life because of struggles with transportation, childcare, affordable housing, food, and affording medications. 80% of the factors that influence health are social in nature, rather than medical. This is where Social Care can make a difference. Social Care supports a person’s overall health and well-being. Through programs like Community Health Workers and the National Diabetes Prevention Program, Social Care helps the people we serve—patients, colleagues, and community members—get access to food, housing, health care, and other supports needed to stay healthy.

Trinity Health’s Community Health Worker (CHW) Program works closely with a patient to assess their social needs, home environment, and other risk factors and ultimately connect patients to services within the community. Our CHWs, through their lived experience, represent the communities they serve and are a bridge between health and social services, and the community.

Additionally, we offer the Trinity Health Community Resource Directory, which is an online portal connecting those in need to free or reduced-cost health and social service resources available through community-based organizations, government agencies, and across all Trinity Health locations. We invite everyone we serve, our colleagues and community members to access the Community Resource Directory by visiting https://communityresources.trinity-health.org.

Examples of Social Care services we offer or can make available for referral (as available locally – not available everywhere) include:

  • Benefit Enrollment Support (Medicaid, supplemental nutrition access programs, light and heating support and more)
  • Diabetes Prevention Program
  • Financial Assistance
  • Food Assistance
  • Connection to Primary Care and Behavioral Health services and supports (inclusive of peer support, substance use and mental health treatment) for the uninsured/and or Medicaid Population
  • Low/no cost medications or medication delivery for persons unable to leave their home
  • Shelter (temporary placement or longer-term supportive housing)
  • Social Isolation programs
  • Tobacco Cessation
  • Transportation Assistance