Many patients have difficulty navigating and receiving needed social services that can often exacerbate their health challenges. By employing community health workers (CHWs) and a network of community referral organizations, the needs of vulnerable patients with chronic conditions can be better met.

In 2018, ARCHI, housed at the Georgia Health Policy Center, convened a small working group representing health care and social service providers, payers, and funders to address barriers to person-centered care. After extensive discussion and research along with national leaders in this field, the group committed to building a real-time, rapid referral network. ARCHI’s role is to assist with the development, implementation and evaluation of this network.

Grounded in a patient-centered model, the Community Resource Hub (CRH) is a network with coaching support and real-time data-sharing among clinical providers and community-based social services. The CRH supports patients with chronic disease management and focuses on addressing their social needs such as housing, nutrition, employment, and transportation. In the CRH model, CHWs are housed within health systems and provide warm handoffs to connect patients with chronic conditions and unmet social service needs to CRH partners. A CHW can support an estimated 50 patients at any given time. CRH partners include community-based organizations. All CRH partners have committed to not only providing a network of support but also data-sharing and interoperability.

The CRH was initially piloted at Grady Health System, Atlanta’s safety net hospital, and Mercy Care’s Decatur Street Clinic, a Federally Qualified Health Center. During the pilots, the majority of patients enrolled in the Community Resource Hub experienced lowered or stabilized their blood pressure and A1C scores. CRH also achieved success in supporting patients’ social needs.

Health Systems Transformation

Strategic Planning