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Creating a remarkable health experience

Front Door Initiative: Connecting Patients to Social Care

Building a comprehensive social determinants of health (SDOH) strategy involves meeting individuals where they are — and for many patients that begins in the emergency department (ED).

At Allegheny Health Network (AHN), clinicians observed that frequent ED visits often had as much to do with challenges faced in a patient’s social environment as they do with underlying medical issues. With more than 80% of a patient’s health determined by SDOH factors like access to healthy food, transportation, and safe housing, addressing social determinants is critical to improving whole health.

Through a grant from the Jefferson Regional Foundation, AHN’s Jefferson Hospital started an innovative program in 2018 to address SDOH factors known as the Front Door Initiative. This program successfully integrates SDOH screenings and makes referrals for long-term support within the duration of a patient’s visit to the ED.

Once referred, the patient is connected to a Front Door Initiative Community Health Worker which guides them to the most appropriate community resources, advocates on their behalf, and stays in close communication for up to four months. This support can be helping patients with rental assistance, transportation, auto repairs, access to healthy food, mental health support, and more. By removing the stress and confusion that often comes with tackling these challenges, the program helps patients find a self-sufficient path forward. This ensures individuals leave their health care experience feeling not only healthier, but more empowered in their everyday lives. 

Since its inception, the Front Door Initiative has seen significant growth. With financial support now coming from the Jefferson Regional Foundation, Highmark Foundation and the Allegheny County Health Department, the program is on track to triple its number of patient referrals for 2022.

In the video below, Mon Valley residents Jamie and Matthew share how this program changed their lives for the better.

[View MP4]

Jamie Braum: Before I met Heather and learned about the Front Door Initiative, I was facing eviction, mostly due to COVID. I didn't work for six months. I didn't know what to do with anything in my life. Everything was just falling apart. I was lost.

Matthew Becerra: Where I would be if I didn't get hooked up with her at the Front Door Initiative, I'd probably be on the streets because I wasn't working at the time and I couldn't pay my rent. And she helped me out a lot. She kept calling me back to make sure everything went through, checking on me. They treated me like a human. They treated me like a like I was their best friend.

Ally Lush: So the Front Door Initiative was started in 2018 through a grant with the Jefferson Regional Foundation, and it was aimed to address the social determinants of health needs for patients that come to the Jefferson Hospital Emergency Department (ED). Social determinants of health actually account for 80% of someone's overall health. I like to think of them as like a three-dimensional web around a person. So, they're all the factors outside of someone's clinical condition that impacts someone's health. So that could be the community that they live in, the safety of that community, the safety in their household, their access to transportation, their access to food sources, like grocery stores, their financial security, the housing stability as well. So, there are a lot of different factors outside of someone's clinical condition that impact their health.

Heather Sims: Community health workers can address the social determinants of health by really being that support system for a patient. They offer their knowledge of the resources that are out there. There's a lot of people that don't know all the resources that are available to them.

Ally Lush: We also work with the emergency department to make sure that, techs, that everybody in the ED knows about social determinants and that the front door is there as an option.

Heather Sims: I think the one trait that's pretty required in this job is just to have a natural ability to connect with people being genuine and empathetic towards somebody else. I think people can really see that and hear that initially when you when you reach out to them.

Jamie Braum: She just said like I just need you to listen, just tell me what you know, do you need anything was and I think I just like burst into tears and I was like I just need everything. Like I have nothing I don't know what I'm doing. I don't know where I'm going. I don't know how I'm gonna get to work. I don't know where I'm going to work. I don't know where I'm gonna live. At that point. I just quit. I was like, this house is so moldy. Shane and I have severe asthma. I'm breathing in mold every day. I can't go in the basement. I'm just done. Like I need to find a new place to live. Like I just didn't have anybody to talk to. And I think that's what made me like, really open up but she said she wanted to listen.

Heather Sims: We were able to have a donor give her first month's rent and a security deposit. We were able to get her car fixed. We were able to have some food delivery sent to her. And we were able to prevent her having an eviction on her record. With all that stress of trying to find a new place, trying to work overtime at Eat’n Park and waitress to come up with more money. Her kids weren't really going to have Christmas. So, we were able to pull a couple of different resources together and be able to get her kids presents for Christmas.

Jamie Braum: Whenever they jumped off the Christmas presents for the kids. I just I cried every time. I've always wanted to just be able to give my kids more than I had growing up. And in that moment, I wasn't able to but they helped me be able to provide for my kids and that's all that I wanted.

Matthew Becerra: I was having a lot of panic attacks that were causing me to get really ill. It was like I couldn't leave my house. I was scared for no reason. There would be consequently my health for a week. I lost my job, and I was having trouble with rent the previous doctor that I was seeing wasn’t treating me right and I just felt like I wasn't getting no help there. AKA we’re taking care of you. You're done. You're out. You're out of your panic mode, go home ya know?

Heather Sims: One of the things is we don't want it to be just like a call center where we just hand them a resource and say here you go. What we wanted to develop was sort of a road to self-sufficiency for our patients. Being that in the beginning we will do it for you. And then in the middle will help you and by the end we really want them to be able to do it on their own. When I finally wrapped everything up, he had gotten a new PCP, got on the right medication, hasn't had any more panic attacks is back to work, and did get the emergency rental assistance for all of their back rent and all their back utility.

Ally Lush: Social determinants, they affect everybody. And there's not a really clear pathway to say this is what you do. When you're facing an eviction. This is what you do when you're under financial stress. There's nobody that says these are the steps you take. And often stress makes it really hard to find those steps that you want to take. The impact that we make is navigating those resources and providing a path forward with patients and really be there in their corner throughout the process.

Matthew Becerra: It meant a lot to me. Like I felt like somebody actually cared. I'm just ready to live my life and enjoy life now. Y'all actually enjoy the weather. Something I haven't done in probably a few years because of my anxiety. My girlfriend sees how improved I've been. It's just it's a world of difference. I’m loving life again.

Jamie Braum: I was at the lowest point in my life, and now I'm not lost anymore. I was just stuck and I'm just like I'm free. That's how I feel. Feel free and happy again.

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