Social Needs Support

Population Health - CHNA - Health IndicatorsClick to Enlarge

Eighty percent of health is determined by factors outside the health care system. Clinical care has greater impact when patients return to healthy environments. Social, physical, and economic conditions in which an individual lives, works, and plays can impact their overall health and quality of life.1

To address this, Cottage Population Health partners with local organizations and Health Leads, a national non-profit organization recognized for their social needs program approach. Together, we have co-created and built new, innovative models and tools for connecting people with essential resources and improving the factors affecting people’s health and well-being.

Employee Resource Connect

Population Health Employee Resource Connect logo

With a strong desire to “start at home” in addressing social needs in Santa Barbara County, Cottage Population Health developed Employee Resource Connect, an intervention linking employees to food, transportation, behavioral health and housing resources. Cottage Employee Health nurses offer employees a brief social needs screener on a tablet device during their annual Employee Health visit.

Resource navigators from Family Service Agency respond to requests for support and resources by email, phone, and/or in person within 72 hours of screening.

In the first year of the program, social needs screening demonstrated food insecurity as a prevalent need among employees. Through the development of a food assistance program, employees who screen positive for food insecurity and choose to participate receive $50 in food support. This is offered in the form of credit loaded onto their employee badges to be used at onsite Cottage dining, a grocery gift card, or three organic boxes of produce from Something Good Organics Community Supported Agriculture.

Employees participating in the program also receive support from a Family Service Agency advocate to assist with identifying long-term solutions to food needs, which may include additional financial support.

Employee Resource Connect – Essential Needs Identified Among Employees in 2019

Employee Resource Connect – Essential Needs Identified Among Employees in 2019Click to Enlarge

Patient Resource Connect

Population Health Resource Connect logo

For those most in need, navigating and connecting to resources can prove challenging in an often fragmented and siloed system. Patient Resource Connect provides support to help patients access the most essential resources. Launched in 2018, the program offers patients an opportunity to complete a brief social needs screener during a visit to the hospital and receive follow-up assistance from a navigator.

Upon entering the hospital, the Cottage Patient Access team screens patients on tablet devices following registration. The screener includes questions on food insecurity, access to transportation, and housing insecurity. After their visit, resource navigators, who are trained staff and volunteers, assist patients with connection to referrals to address their needs. Assistance is provided via email, phone, and/or in person within 72 hours of screening and continues until patients successfully access the resource.

Initially starting in the Goleta Valley Cottage Hospital Emergency Department, Patient Resource Connect aims to support a system-wide approach for connecting patients to essential resources. Programs to increase resources and address the most prevalent patient needs are currently in the pilot phases.

Resource navigators from Family Service Agency respond to requests for support and resources by email, phone, and/or in person within 72 hours of screening.

Patient Resource Connect – Essential Needs Identified Among Patients in 2019

Patient Resource Connect – Essential Needs Identified Among Patients in 2019Click to Enlarge


1 County Health Rankings. (2020). County Health Rankings Model. Retrieved from http://www.countyhealthrankings.org/our-approach.

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