CHI Health wanted to assess the effectiveness of a program to address social and environmental determinants of health.

Social and environmental factors play an important role in a person’s health and well-being. Healthcare organizations seeking to support their patients’ health must understand and address the social and environmental factors that affect their patient population.

To meet this need, CHI Health developed the Community Link Program, which provided patients in two of their clinics in Omaha, Nebraska, with an integrated, patient-centered model of care that supports them in addressing social needs. Patients at these clinics were screened and provided referrals, as appropriate, to support services, such as low-cost transportation options and vouchers for utilities.

These patients were also provided access to Community Advocates and Student Advocates, who worked to ensure that appropriate connections were made to address patients’ social needs and reduce their barriers to care. The Community Advocates built relationships within the community and helped create bridges between available resources and the clinics, while the Student Advocates were health sciences students from Creighton University’s Interprofessional Education Curriculum who supported the program as part of their required coursework. 

CHI Health wanted to know if the Community Link Program was making a difference.

NORC developed a plan for CHI Health to use to evaluate the Community Link program.

Our plan was designed to help CHI Health answer questions related to the program’s impact on participants’ physical health outcomes and quality of life as well as measure participants’ satisfaction with the program, the degree to which the program was implemented with fidelity, and CHI Health’s return on investment. The plan linked specific evaluation questions to proposed process and outcome measures as well as to new and existing data sources.