Flip No. 13

Address a patient’s most basic needs

Health Leads connect patients to community resources.

By Flip the Clinic

When patients and their families seek medical care, they often face critical challenges in their lives at the same time; they have little food, they have no job, or they struggle to keep up with bills for gas and electricity. Not surprisingly, these challenges affect a patient’s health. Health Leads was founded in 1996 with idea that addressing all patients’ basic resource needs should be a standard component of patient care. In the clinics where Health Leads operates, physicians can prescribe food, heat, and other basic resources their patients need to be healthy, alongside prescriptions for medication.

How do they find the time? Certainly doctors, nurses, and even social workers are too overburdened to take on the work of providing additional support.

So Health Leads taps a corps of highly-trained college students, called Advocates, to work side-by-side with the patients. When patients get a prescription for, say, heat, they take their prescriptions to a Health Leads’ desk in the clinic’s waiting room. There, Advocates help patients navigate the complexity of the resource landscape, from tracking down phone numbers, to printing maps, to securing transportation, to completing applications. Advocates follow up with patients regularly by phone, email, or during clinic visits. Relationships may be long-term or short-term based on patients’ needs and preferences.

It’s a model that works. After nearly two decades, Health Leads has learned that there are five codifiable, replicable elements required to build scalable infrastructure to address patient resource needs.

1. Seamless clinical integration
Health Leads takes the core elements of care delivery and repurposes them to address a patient’s broader needs. When patients show up for primary care appointments, they’re asked a few questions about their basic resources: “Are you running out of food at the end of the month? Are you worried about paying your utilities bills?” So when the doctor begins the visit, she knows the essentials: height, weight, and is there enough food at home.

And the doctor can do something about it. Physicians and other providers can use the electronic medical records (EMR) to prescribe healthy food, heat in the winter, job training, and refer patients to Health Leads like any subspecialty referral. Advocates, in turn, provide real-time updates via the EMR to rest of the clinic team on whether or not a patient got the needed resource, yielding better informed clinical decisions.

2. Well-trained lay workforce
Health Leads’ corps of college student Advocates are competitively recruited, intensively trained, and supervised by full-time, clinic-based staff with social work/case management experience.

3. Robust patient engagement
Advocates follow-up weekly with patients until they secure the needed resources, providing targeted guidance on how to navigate financial, linguistic, and bureaucratic obstacles. Ninety percent of patients with whom Health Leads works successfully secured at least one basic resource critical to their health or reported that they could secure the resources they need with the information provided by Health Leads without further assistance.

4. Sophisticated technology
Health Leads has developed a technology platform that connects patients with resources that fit their needs—and their location. Think of it as the Yelp of health resources. When an Advocate enters a patient’s demographic information and resource needs, Health Leads’ web-based interface automatically generates results in the patient’s neighborhood that are currently open. The database is continuously updated by a team of undergraduate “resource coordinators” who devote 400 hours a week to ensuring that every resource in the communities they serve have up to date phone numbers, addresses, services, hours, and languages spoken.

5. Data and analytics
This technology platform also includes strong back-end analytics capacity, enabling Health Leads to equip clinics with real-time, population-level data, like the type and cost of care required to deliver quality outcomes for patients.

Case Study

Ninety percent of patients working with Health Leads successfully secured at least one basic resource critical to their health or reported that they could proceed with the information provided to them.

In the Dimock Center, a federally qualified health center in Roxbury, MA, Health Leads helped the center’s pediatric social worker increase services to children by 169 percent. Because Health Leads supported many of the patients’ basic needs, the clinic’s quality of care improved and additional revenue was generated for the health center.

At Children’s National Medical Center in Washington, DC, parents of children under age two who received coaching by Health Leads advocates used the ER about 34 percent less for non-emergent cases over a 6 month period.


  • Joe

    I think of the psychiatric community when comes to basic needs. When many of these clients are in crisis they forget what is told to them in the hospital setting, regarding resources. Review with them daily the resources available to them in their area. Provide them with something as simple as a phone book and instruct them on how to use. Provide information regarding the internet and basic computer use, suggest going to the community library and utilizing a computer if they don’t have access to one. Sometimes as providers we forget about the basics.

  • Bridget Ellsworth

    This is a great concept. If we can’t help our patients with basic needs, our health interventions will not keep the patient healthy. So many times I have discharged a patient from the hospital and know they go back onto the streets or very poor housing conditions and I have felt like I have let them down. I may have helped them heal through their latest health crisis, but their living conditions will have them back in acute care too soon. I like this concept also because it is a “one stop shop”. The patients can discuss their health needs with their doctor and can meet with an advocate quickly who will help them with their basic needs or information.