A major health system located in Northeast Ohio was embarking on the development of a new way to deliver care.  The health system was creating a program to screen Medicaid and Medicare beneficiaries for social determinants of health and then appropriately navigate them to receive assistance from community service providers.

The goal of this ongoing project is to increase awareness of community resources for individuals in the community; to increase the connections between high-risk individuals and community resources; to optimize community capacity to address health-related social needs; and to reduce inpatient and outpatient healthcare utilization by addressing unmet health-related social needs through referral and connection to community services.

To achieve this goal, the health system needed to develop a network of community service providers to: (1) serve as the key connection points for at-risk community members; and (2) serve on a community advisory board.  LNE Group was engaged to build this network of community service partners.


LNE Group’s Strategic Advisory team was deployed to identify potential community service providers across a broad list of categories, to manage outreach to each provider, and to confirm their role in the program.  The team first catalogued potential community service providers and identified appropriate contacts within each organization.  More than 100 local community service providers were considered as project collaborators, from which the client narrowed the list to approximately 70 target organizations.


Through LNE Group’s involvement, nearly 80% of those targeted organizations agreed to collaborate as part of the local community service provider network as this project is deployed.  This collaboration has enabled the hospital system to seek federal funding for the project, and will serve as the basis for ongoing collaborations that will address deep-seated community health challenges intrinsic to core neighborhoods in the City of Cleveland, Ohio.

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