Written by: Center for Care Innovations
High Costs and Complex Needs Beyond the Clinic

From claims data, Community Health Center Network (CHCN) realized a small percentage of its members were racking up immense costs and utilization rates, especially hospitalizations and emergency room visits. This information was paired with a series of ethnographic interviews to better understand the variety of obstacles facing patients and how they contribute to the high price of medical care.

Technology Hub member CHCN and its member health center organizations know that the “social determinants of health” − trauma and lack of access to healthy food, transportation, and housing − have a huge impact on the lives of patients in the safety net. CHCN sought to reach out to these patients, establish strong relationships, and assist them in meeting their social, medical and behavioral health care needs. It takes more than a medical provider in an exam room to transform health for patients who face challenges in many aspects of their lives.

Guided by its mission and a patient-centered approach, CHCN focused on strengthening connections beyond the clinic to address the high costs and complex needs in the communities it serves: “We are charged with being good stewards of our health care dollars and wanted to prevent needless suffering and optimize health in our communities.”


Illustration by: Jonny Goldstein / Photo by: Leonardo Correa, Courtesy of Community Healthcare Network