Complex care providers are increasingly aware of the social and environmental factors that contribute to poor health outcomes. In response, many providers are finding ways to address identified non-medical needs by establishing connections to an array of community resources (e.g., food banks, employment services). This webinar featured speakers from AccessHealth Spartanburg in South Carolina and Petaluma Health Center in Northern California who shared strategies for addressing social determinants of health (SDOH) through screening approaches, innovative technologies that track social service referrals, and development of strong connections with community partners.

Providers, health systems leaders, and other interested stakeholders can replay this 90-minute webinar, made possible through support from the Robert Wood Johnson Foundation, to learn how providers serving individuals with complex health and social needs are addressing SDOH. The webinar is a product of Transforming Complex Care, a national initiative focused on advancing innovations in complex care.


I. Welcome and Overview of Addressing SDOH in Complex Care Programs

Speaker: Caitlin Thomas-Henkel, Senior Program Officer, CHCS

Caitlin Thomas-Henkel welcomed participants and introduced the presenters. She described how complex care providers are increasingly assessing peoples’ unmet social needs, forming partnerships with community-based organizations, and connecting individuals to social supports.

II. Connecting Uninsured Patients to Care and Social Supports

Speakers: Carey Rothschild, Director, and Summer Tebalt, RN Case Navigator, AccessHealth Spartanburg, South Carolina

Carey Rothschild and Summer Tebalt discussed how they assess uninsured clients with complex health and social needs and connect them to community-based providers and also described their efforts to build a network of social supports in the community.

III. Identifying and Addressing SDOH in Complex Populations

Speakers: Jessicca Moore, Associate Clinical Director and Director of Innovations, Petaluma Health Center, Sonoma County, California

Jessicca Moore described Petaluma Health Centers’ approach to screening and managing complex populations’ social needs as well as the health center’s experience using an electronic platform to track patient connections to social services.

Reactor: Derek Delia, Director of Health Economics and Health Systems Research, MedStar Health Research Institute, who led the evaluation of the Transforming Complex Care (TCC) sites, reflected on the TCC sites’ efforts to address SDOH.

IV. Q&A Session and Closing Remarks