Addressing social needs, particularly among vulnerable populations, is critical to improving outcomes and ensuring health equity. In Portland, Oregon, Project Access NOW (PANOW), a local community-based organization (CBO), is improving the health and well-being of uninsured and low-income individuals by connecting them with health care, non-medical services, and other community resources. The C3 Community Assistance Program (C3CAP), a PANOW service supported by six area hospital systems and two coordinated care organizations (CCOs), helps individuals successfully transition from the emergency department and inpatient hospital stays back to their homes by addressing social determinant needs that impact health and recovery. The end goal is simple: to keep people healthy and avoid unnecessary readmissions.
This profile looks at a partnership including Project Access NOW, six area hospital systems and two coordinated care organizations that is connecting individuals in Portland, Oregon to social services to ensure safe discharge from emergency and inpatient hospital settings.