Host organization: Atlanta Regional Collaborative for Health Improvement (ARCHI)

ARCHI is a multisectoral, public-private partnership of over 100 organizations aligned in a 28-year commitment to improving health outcomes in the core metro Atlanta area. Since 2012, ARCHI has convened the broader Atlanta community four times a year to discuss the health challenges and health inequities driving poor health outcomes. Each quarter, 150+ individuals and organizations committed to upstream, cross-sector work gather to learn and network together. They represent a broad range of perspectives, including representatives from health providers, government, nonprofits, and social services.

Issue: Disconnect between patients and social services

The Atlanta area is rich with several top-tier healthcare systems and a strong network of public and private social services. However, despite receiving information and referrals from clinicians, case managers, social workers, or community health workers, patients often have difficulty navigating and then receiving the social services that can address not just the symptoms of, but the drivers of their health challenges. In many cases, clinical conditions worsen and health outcomes deteriorate. Several factors contribute to this problem:

  • Care providers are not able to access real-time availability for services or make real-time referrals. It often falls to a patient already facing significant complexity to follow up and seek out services on their own.
  • The path for patients is not linear. Patients may have difficulty navigating the system without a warm handoff or more hands-on case management and problem-solving.
  • Maintaining a working knowledge of each service’s eligibility criteria is difficult for health system staff.
  • When referrals are successful and individuals receive services, there is no mechanism for sharing data, limiting the ability to follow up in the clinical setting or track the impact of these additional supports on health or healthcare expenses.

Convening

ARCHI and the National Center will convene local partners to further develop support for a real-time, rapid referral network with the larger Atlanta community. Participants will consider the application of best practices and lessons learned from outside Atlanta, identify incentives for the unprecedented levels of collaboration needed to bring this model to scale in Atlanta, and showcase the work done to date and the champions committed to advancing next steps. This convening will accompany referral network pilots in a local Federally Qualified Health Center and Atlanta’s safety net hospital. These pilots will focus initially on housing, nutrition, and transportation needs.

Outcome: Increased community engagement and buy-in around a real-time, rapid referral network

This convening will enhance shared understanding of the implications and opportunities of a referral network. It will begin to address large inequities and systemic challenges in the community and leverage current momentum for the project in the Atlanta community.

For more information on this event, please contact the host organization.