Navigation and Support

Bringing healthcare within reach

Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and healthcare.

WellSpan actively screens patients for social barriers such as food, housing and transportation. In the last three years, our teams have screened half a million unique patients and identified more than 45,000 people as having at least one social insecurity.

WellSpan's Ambulatory Care Management team leads our efforts to support patients in overcoming social barriers, through communication with payors and social service providers.

This team receives referrals from clinical care teams through a virtual outreach center, which is made up of nurses, social workers and community health workers. The team diligently works daily to process incoming referrals, perform chart reviews and engage patients to develop a comprehensive care plan.

Ambulatory Care Management processes nearly 14,000 electronic referrals a year received from WellSpan clinical teams directly through our electronic health record. Additionally, the team assists many patients through telephone and email referrals.

Supporting patients through partnership and collaboration

Recently, the Ambulatory Care Management team began working with social service providers and insurance payors with a goal to share resources, identify rising- or high-risk patients in need of care management services and connect individuals to the appropriate level of care in a more dignified and streamlined way.

These efforts lay the groundwork for a shared case management approach connecting WellSpan and local social service providers in a way that allows individuals a single point of entry to easily navigate and receive help.

To improve navigation for providers and individuals in need, WellSpan introduced HeretoHelpAll.org, a community-based web-based resource and referral platform in February 2023.

While our referral network continues to grow, nearly 4,000 people have already accessed the tool, including WellSpan providers, patients, caregivers, social service providers, and community members.

These users collectively performed 15,000 searches for support with about 5,000 connections being made.

WellSpan seeks to partner with more community-based organizations to promote the use of this platform. By working together, WellSpan and partners can ensure that individuals in need can find the right help at the right time.

The Medical Legal Partnership program partners with Mid-Penn Legal Services and the Pennsylvania Immigration Resource Center (PIRC) to help individuals who have health-harming legal needs.

The program served nearly 200 people in York in the last year to obtain income, address landlord-tenant issues, secure government benefits and resolve housing and bankruptcy issues. Expansion efforts to other counties are under way.

WellSpan Special Programs began aligning with the strategic initiatives of the York County Reentry Coalition to support timely access to medical and behavioral health care for community re-entrants, as well as to engage with vested community partners to reduce barriers related to social determinants of health.

Engaging with York County Prison staff, WellSpan Special Programs has worked to develop transition plans in support of the re-entrant's journey, to act as a conduit for information transparency, and to connect processes by providing support for reentering inmates presenting with medically acute needs.

Outcomes include:

connecting participants with housing, insurance, primary care, medication management and care provisioning
a 9 percent participant recidivism rate
reduced hospital admissions and readmissions

This team began partnering with Franklin Together to support re-entrants in the Franklin County Community who face medical and social barriers upon re-entering from incarceration. Between the two counties, these teams have supported over 130 re-entrants.

Featured Searches

Featured Searches

Navigation and Support

Bringing healthcare within reach