Complex care is about addressing people’s social and medical needs, but most hospitals and health systems are only set up to do the latter. And while hospitals can make great strides towards better care by using data to identify individuals with complex health and social needs, deploying interprofessional teams, and improving care coordination, much of our health is determined by what happens outside of the hospital walls. That’s why forward-thinking hospitals around the country are making community health equity a core part of their strategy.

Rush University Medical Center has been located in Chicago’s West Side neighborhood since 1873. Robyn Golden, Associate Vice President of Population Health and Aging, has led Rush’s efforts in complex care with the creation of the Bridge Model, an innovative transitional care model for older adults with complex health and social needs.

“Being a social worker, traditionally I’ve looked at not just people and their behavior, but people within the context of their environment,” she said.

Complex care at Rush has expanded from a pilot program for their aging population to consulting for their entire Medicaid accountable care organization population. The next step, said Robyn, is “owning our community… recognizing that individuals may have issues that need to be addressed, but it’s not all about their individual issues, it’s about structural and societal issues.”

Addressing these structural and societal issues required creating strong partnerships with other organizations and leaders in the West Side community, and it also required the organization to commit to health equity as a strategy. The Robert Wood Johnson Foundation defines health equity as everyone having a fair and just opportunity to be healthier. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and healthcare.

In early 2018, a series of meetings and listening sessions between Rush and other area healthcare and community-based organizations, residents, and faith leaders culminated in the launch of West Side United.

David Ansell, Senior Vice President for Community Health Equity at Rush, calls West Side United an “equity collaborative” that brings local institutions, community organizations, and residents together to create a “united West Side voice.”

At neighborhood listening sessions, many of the institutional representatives expected to hear that violence was residents’ biggest concern. But violence did not come up. Instead, what residents said they needed was jobs, support for kids who were feeling hopeless, and business development. This summer, the hospitals and health systems of West Side United are leveraging their contract relationships to ensure that all 20,000 kids on the West Side have a summer job and mentorship.

West Side United is a collective of 23 member organizations, led by a 16-member planning committee with half of the seats reserved for West Side residents. Their priority initiatives for 2018 weave together impact investing in under-resourced areas, expanding community health worker programs and co-located primary and behavioral health, increasing local internships and hiring, and improving access to healthy food.

“It’s really important that this was all done together,” he said. “We only succeed through meaningful partnerships. We have lots of programs, but the ones that move the dial are ones that have partnership, trust, willingness to fail together, and no one taking the credit.”

This approach rooted in community partnerships is already having an impact on the health of Rush patients with complex health and social needs. Rush now has a dedicated navigator connecting uninsured patients with complex care needs from Rush’s inpatient unit for followup care at nearby CommunityHealth Clinic, the largest free clinic in the country. The referrals are working: the 30-day hospital readmission rate for patients connected to CommunityHealth Clinic is a stunning zero percent.

Key to all this work, David said, is naming racism as a root cause of poverty and poor health outcomes and working aggressively toward better representation both within and outside of institutions.

“If [diverse] voices are not at the table in leadership to help make decisions, you’re never going to make the right decision,” he said. “Places that have made [health equity] a strategy will do better in the long run, but it’s not just about the business case: it’s about repairing these historical injustices together.”

And having the right partnerships in place, said Robyn, means that complex care teams working downstream can move from screening for social determinants of health to intervening.

“You simply have to look at our numbers compared to other countries,” she said. “When [countries] invest more in social care, their health outcomes are better. And we don’t do that in this country.”


Rush University Medical Center and the Robert Wood Johnson Foundation are co-hosting Putting Care at the Center 2018 with the National Center December 5-7 in Chicago, Illinois. Learn about presentation opportunities, our Consumer Scholar program, and more on the conference website.