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Bringing Healthcare Within Reach

Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and healthcare.

WellSpan actively screens patients for social barriers like food, housing and transportation. In the last three years, our teams have screened a half million unique patients with more than 45,000 people identified as having at least one social insecurity. Through communication with payors and social service providers, optimal support in overcoming identified barriers can be achieved.

WellSpan's Ambulatory Care Management team leads our efforts to support patients in overcoming social barriers. This team receives referrals from clinical care teams through a virtual outreach center, which is made up of nurses, social workers and community health workers. The team diligently works daily to process incoming referrals, perform chart reviews, and engage patients to develop a comprehensive care plan. Ambulatory Care Management processes nearly 14,000 electronic referrals a year received from WellSpan clinical teams directly through our electronic health record. Additionally, the team assists many patients through telephone and email referrals. 

Supporting Patients Through Partnership and Collaboration

Recently, the Ambulatory Care Management team began working with social service providers and insurance payors with a goal to share resources, identify rising- or high-risk patients in need of care management services and connect individuals to the appropriate level of care in a more dignified and streamlined way. These efforts lay the groundwork for a shared case management approach connecting WellSpan and local social service providers in a way that allows individuals a single point of entry to easily navigate and receive help.

To improve navigation for providers and individuals in need, WellSpan introduced, a community-based web-based resource and referral platform in February 2023. While our referral network continues to grow, nearly 4,000 people have already accessed the tool, including WellSpan providers, patients, caregivers, social service providers, and community members. These users collectively performed 15,000 searches for support with about 5,000 connections being made. WellSpan seeks to partner with more community-based organizations to promote the use of this platform. By working together, WellSpan and partners can ensure that  individuals in need can find the right help at the right time. 

Success Story

Recently, team members with the WellSpan Restorative Pain Program in York lent a helping hand to community members by using Here To Help All. One patient was experiencing homelessness and was sleeping in her car. Another person was struggling with paying rent and utilities while trying to find a job. Through Here To Help All, team members helped the first patient with a referral to a shelter at Bell Socialization. They also helped the other patient find financial assistance for utility payments and referred the person to Vocational Rehabilitation Services for assistance finding employment.

"The overall program has made a tremendous impact on how I am able to help my patients as a care coordinator at the Restorative Pain Program. I'm now able to send patients out of here with information for resources," says Angela Brown, clinical team leader at WellSpan Restorative Pain.

Do you know of someone in need or that can benefit from these resources? Visit to search for available services.

Additional Programs

Medical Legal Partnership

This program partners with Mid-Penn Legal Services and the Pennsylvania Immigration Resource Center (PIRC) to help individuals who have health-harming legal needs. The program served nearly 200 persons in York in the last year to obtain income, address landlord-tenant issues, secure government benefits and resolve housing and bankruptcy issues. Expansion efforts to other counties are underway.

Prison Reentry

WellSpan Special Programs began aligning with the strategic initiatives of the York County Reentry Coalition to support timely access to medical and behavioral health care for community reentrants, as well as to engage with vested community partners to reduce barriers related to social determinants of health. Engaging with York County Prison staff, WellSpan Special Programs has worked to develop transition plans in support of the reentrant's journey, to act as a conduit for information transparency, and to connect processes by providing support for reentering inmates presenting with medically acute needs. Outcomes include participants connected with housing, insurance, primary care, medication management and care provisioning; a 9% participant recidivism rate; and reduced hospital admissions and readmissions. This team began partnering with Franklin Together to support re-entrants in the Franklin County Community who face medical and social barriers upon re-entering from incarceration. Between the two counties, these teams have supported over 130 re-entrants.