Cleveland Clinic Program Tracks Outcomes of Referrals to Community Resources

Cleveland Clinic and Unite Us are collaborating to link Northeast Ohio healthcare and social care providers through a shared electronic resource referral platform.

Through this platform, Cleveland Clinic will enhance its capability to serve patients who struggle with mental health and access to housing, food, employment, or other health determinants by directly connecting them with community organizations to address those needs, while also tracking the outcomes and impact on individuals’ health.

Referring patients to community social care organizations helps address health equity, racial disparities and social determinants of health which, according to the National Academy of Medicine, account for 80 percent of a person’s overall health. By incorporating the Unite Us technology platform, Cleveland Clinic will be part of a national coordinated care network and the Unite Ohio statewide coordinated care network.

“By engaging with like-minded partners, we can make a difference in creating a healthier community for everyone,” said Adam Myers, M.D., Chief of Population Health at Cleveland Clinic. “This new platform enables us to better connect patients to community-based organizations we partner with to meet those needs. This connectivity is essential for us to ensure those needs are addressed and better understand the impact of these partnerships.”

All Cleveland Clinic patients regardless of insurance are eligible for this support. Services in Ashland, Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, Medina, Portage, Stark, Summit and Wayne counties in Ohio are included in the program. Community resources and organizations that Cleveland Clinic can track through this platform are the Benjamin Rose Institute, Better Health Partnership, Greater Cleveland Food Bank, Home Instead Senior Care and United Way of Greater Cleveland.

“We know many of our patients are struggling with health-related social needs that limit their potential to achieve optimal health and wellness,” said Nazleen Bharmal, M.D., Ph.D., M.P.P., Associate Chief of Community Health & Partnerships at Cleveland Clinic. “Through this effort, and with our regional community partners, we will increase our reach and effectiveness in addressing those individual needs.”

Program implementation is expected to be complete by third quarter of 2021.

Cleveland Clinic’s commitment to the community will enhance the region for generations. Recent efforts that illustrate the health system’s pledge include implementing a school-based healthcare program; providing high speed internet to surrounding neighborhoods; joining OneTen, a coalition of organizations committing to train, hire and advance one million Black Americans over the next 10 years into family-sustaining jobs with opportunities for advancement; expanding the ASPIRE Nurses Scholar Program; investing in the JobsOhio initiative; and delivering Thanksgiving dinners to the community.