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Roles Outside Of Traditional Systems

The Center for Care Innovations selected West County Health Centers as one of seven organizations to participate in Roles Outside of Traditional Systems, or ROOTS, a one-year learning collaborative focused on the role of community health clinics in addressing patients’ social needs.

West County Health Centers (WCHC) started focusing more explicitly on social determinants of health (SDH) approximately five years ago, inspired by thought leaders like Victoria Sweet and Rishi Manchanda, who championed a different, more wholistic approach to medicine. In 2017, WCHC began implementing PRAPARE, a tool consisting of a set of national core measures used to collect and act on patients’ social needs. WCHC had also been using Purple Binder and Aunt Bertha (two online social service resource connection platforms) to refer patients to non-medical services since 2017. The ROOTS grant provided an opportunity to take their SDH work to the next level, while taking advantage of the health center’s strong data capacity.

The following case study was prepared by the Social Interventions Research & Evaluation Network (SIREN) at the University of California, San Francisco.


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Case Study: Building a Collaboration with West County Health Centers to Address School Absenteeism

July 10, 2019
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By Meaghan Copeland
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The Center for Care Innovations selected West County Health Centers as one of seven organizations to participate in Roles Outside of Traditional Systems, or ROOTS, a one-year learning collaborative f…

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Case Study: Cultivating Community Partnerships to Address Patient Employment Needs

June 7, 2019
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Petaluma Health Center worked to strengthen their PRAPARE implementation and foster strategic partnerships to develop job training and employment services for under- or unemployed patients.

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Case Study: Developing a Whole-Person Case Management Program for People Exiting the Criminal Justice System

May 29, 2019
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St. John’s used the ROOTS grant opportunity to develop and refine their RISE program. RISE (Re-entry Integrated Services, Engagement & Empowerment), which was launched in the fall of 2017, provi…

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Case Study: Incorporating Community Partners Into an Integrated Social and Behavioral Health Model to Address Food Insecurity and Housing

May 29, 2019
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LAC+USC worked to integrate patient social and behavioral health needs into primary care clinics in the late spring of 2016. With the ROOTS grant, the team saw an opportunity to improve food and housi…

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Case Study: Expanding Access to Healthy Food at LifeLong Medical Care

May 17, 2019
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LifeLong Medical Care used the ROOTS grant to pilot a food insecurity screening and referral intervention in one primary care clinic with the goal of eventually expanding systemwide.

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Case Study: Boosting Teamwork Around Social Needs Screening at Asian Health Services

May 2, 2019
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Asian Health Services saw an opportunity to expand its PRAPARE work and improve its response to the needs surfaced through screenings.

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Case Study: Screening Youth for Food Insecurity at Northeast Valley Health Corporation

March 27, 2019
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By Kendra Chaikind
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Northeast Valley Health Corporation focused on screening and referring for food insecurity, a top social risk for its patient population, in patients 12 through 17 years of age at two of its clinical…

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Webinar: The Many Ways Safety Net Clinics Finance Social Programs

March 25, 2019
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The Social Interventions Research & Evaluation Network (SIREN) at UCSF hosted a webinar on strategies safety net clinics use to finance social needs initiatives. Speakers included:

Laura Got…

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Advice for Tackling the Social Determinants of Health in Your Clinic

September 18, 2018
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By Kendra Chaikind
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Our ROOTS teams share advice for tackling upstream challenges, whether you’re just starting out or expanding this work.

We’re Here to Help

We share practical innovations to help your organization revolutionize health care for historically underinvested communities.

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