The integration of clinical and community services address the unmet social needs of seniors, which significantly affect health outcomes and costs. This study includes 25-item surveys and interviews with key personnel from a Senior Health Center (SHC) and a Community-Based Organization (CBO). The interviews covered 7 SHC staff, including a geriatrician, pharmacist, nurse, and others, and 6 CBO staff, including case managers and management coordinators. The findings emphasize the need for coordinated care to bridge clinical services and community resources effectively.
This study proposes creating a centralized care coordination hub that includes a community-based social worker and a tech-enabled communication platform. This hub would connect senior patients with necessary resources, streamlining communication across settings. Additionally, 50% of SHC providers saw value in sharing patient data across settings in real time, despite logistical challenges. The document also underscores the benefits of leveraging ongoing contact with patients and improving communication between clinical and community providers, aiming to improve health outcomes and quality of life for seniors by addressing their unmet social needs.
