Story image
Gen-H Connect Spotlight: UC Health
UC Health, the region’s only adult academic health system, is focused on impacting community health by delivering care beyond their walls.

The Health Collaborative’s Gen-H Connect team is working to address health-related social needs with fifteen partner organizations to provide screening and navigation for Medicare and Medicaid beneficiaries in Hamilton, Butler and Warren counties. Funded by the Centers for Medicare and Medicaid Services (CMS), the Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current healthcare delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries - through screening, referrals and community navigation services - will impact healthcare costs and reduce healthcare utilization.

UC Health, the region’s only adult academic health system, is focused on impacting community health by delivering care beyond their walls. 

UC Health is committed to providing services that address the social determinants of health, and provide a strong foundation for the Greater Cincinnati community. 

To accomplish this important goal, UC Health partners with The Health Collaborative to conduct social needs screenings in its Emergency Department, OB/GYN inpatient unit, psychiatry inpatient unit and one of its primary care clinics.

The social needs screening addresses five domains of health-related social needs: food, housing, utilities, transportation and interpersonal violence. In light of the current public health crisis, community-dwelling beneficiaries may need these services more than ever before. 

Despite these unprecedented times and the impact on our healthcare professionals, UC Health has remained steadfast in conducting social needs screenings to connect community members with the services they need.

UC Health is a unique partner site in that they currently have two dedicated community health workers (CHWs) who are responsible for their continued success in this model. We sat down with site lead Donna White, manager of ambulatory clinical operations at UC Health, and community health workers Monica Hamilton and Nicole Murray, to gain further insight into their success. 

Since the beginning of the pandemic, UC Health reports seeing an increase in need for transportation, food security and steady housing. For example, many patients have become, “fearful of taking public transportation because they are worried about contracting COVID-19. This prevents people from coming to appointments,” according to Monica.

Not only will issues with transportation prevent beneficiaries from attending medically necessary appointments, but they also present significant challenges in accessing food, household supplies and other essential items. According to AHC leadership, efforts by UC Health are helping to alleviate this burden. Records show that for the month of April 2020, UC Health is screening at 60.52% of their expected monthly goal. Implementation of remote screening has allowed them to increase screening rates by almost 30% since the start of the pandemic.

We were also interested in knowing how UC Health has been able to continue screening during these unforeseen times. Given model flexibilities, their CHWs can work from home and conduct screening remotely. Though, “Evidence has shown that face-to-face screenings have positive results,” according to Donna, they are able to now reach out telephonically to beneficiaries to address their needs.

To accommodate these flexibilities, CHWs review clinic schedules up to five days in advance, review unit admissions for OB/GYN, psych units or Emergency Department visits over the past five days to perform screenings. This process is the reason that UC Health remains one of the highest screening sites to date. 

UC Health has also developed solutions that allow non-COVID-19 patients access to its services during the pandemic. “UC Health is inclusive to all patients and treats all patients equally—including those who are not affected by COVID-19,” said Donna. Their primary goal is to ensure access to care for everyone who may need their services. To accommodate patients who may or may not have been diagnosed with COVID-19, UC Health is offering virtual visits via phone, video and e-visits.

Representatives at UC Health also report that the AHC model has helped support their mission and objective related to addressing social determinants of health. 

“The social determinants of health screening tools help us identify additional patients who need care,” shared Monica. 

“Often, patients are identified within the system either through individual reporting or by traumatic episodes. The screening tool helps us further identify patients who may be at risk,” Nicole added.

The screening tool also provides a comprehensive questionnaire for capturing needs within the five domains. To date, UC Health has completed over 1,300 screenings, with a navigation conversion rate of over 78%.

The Gen-H Connect team is proud to partner with UC Health in addressing the health-related social needs of our community, especially in this time of great necessity. For more information about UC Health, please visit



The project described was supported by Funding Opportunity Number CMS 1P1CMS331598-01-00 from the U.S. Department of Health & Human Services (HHS) and Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors, and do not necessarily represent the official views of HHS or any of its agencies.