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.