Healthy Lifestyle

Nuvance Health is bridge to at-risk patients and social determinants help

Danbury Hospital Emergency Department


More people today are hungry and not having their basic needs met — driving up their risk for emergency healthcare services, according to Nuvance Health Accountable Health Communities Model data for western Connecticut.


About 11,000 patients were screened by Nuvance Health and its partners during the COVID-19 pandemic and more than 20 percent were struggling with basic needs, such as meals, a place to live and transportation. Surprisingly, screeners found that even in more affluent communities, such as Southbury, New Haven County, as many as one out of five screened patients had unmet needs that could impact their health.


On May 1, Nuvance Health kicked off its fifth year as an Accountable Health Communities Model bridge organization, which involves the use of federal award dollars to connect at-risk patients with community organizations that can address their basic needs and, hopefully, improve their health.


“We understand the importance of focusing on the social determinants of health and have always been a leader and partner to do that,” said Dr. John Murphy, president and CEO of Nuvance Health. “The pandemic has really highlighted the importance of this work, and we’re glad to be part of making a difference in the lives of our patients and communities.”



Nuvance Health’s legacy Western Connecticut Health Network was awarded the Accountable Health Communities Model cooperative agreement on April 6, 2017, by the U.S. Centers for Medicare and Medicaid Services. Learn more about the federal program here.


The $4.5 million, five-year grant includes Danbury, New Milford and Norwalk hospitals, Nuvance Health Medical Practice in collaboration with Griffin and Middlesex Health.


The award funded screeners and navigators, who screen patients of emergency departments, birth centers, primary care offices and health clinics. They interview patients about social determinants of health, defined as difficulties with housing, food, electricity and heating bills, and transportation, as well as interpersonal violence.


Screenings began on July 1, 2018, and about 45,000 were conducted through April 15, 2021.


“We are now entering our final year of screening, and we’ve been able to help more than 5,000 of our most vulnerable patients,” said Dr. Robert Carr of Nuvance Health’s Accountable Health Communities Model initiative. “This makes a tremendous impact on our communities, in collaboration with our partner organizations,” Carr added.



Of those screened prior to March 7, 2020, or pre-pandemic, the most common needs identified were food insecurity (50%), transportation problems (38%), living situation (34%) and utilities (26%).


During the pandemic, however, food insecurity saw an increase to 62%, followed by utilities (31%), according to Nuvance Health data between March 8, 2020, and April 15, 2021. Transportation and living situation improved (35% and 30% respectively).


“The need for necessities like food increased dramatically during the pandemic while other needs declined a bit because of COVID-19 relief programs, such as stimulus checks and eviction moratoriums,” Carr said. “The program is nimble and has been able to pivot during the pandemic to meet patients’ changing needs as they develop.”


Of those struggling, 55 percent had at least two prior emergency department visits, which makes them at “high risk” and eligible for an individualized action plan to resolve their reported need or needs. A team of navigators helps patients connect with appropriate services in the community to meet their needs.


“They are very grateful to be asked about their situations and often, it is the first time they have been asked,” said Stacey Brusca, a supervisor and lead screener for the program. “Some have never needed financial help and lost their incomes during the pandemic. Others have been frustrated and given up hope of help.”


As one of 28 organizations participating in the Accountable Health Communities Model, Nuvance Health is helping CMS determine if healthcare systems can reduce emergency department utilization through this model of care. Early results are pointing to yes: The Nuvance Health intervention group has 78 fewer emergency department visits than the control group during the first years.


Next steps

Now, in year five, the health system wants to take it to the next level, which includes bringing together various food pantries, social services, homeless shelters and more to ask: How can we work together, maximize our helping hands and have the biggest impact?


“We don’t want to just identify needs; we want to identify solutions,” Carr said.


Learn more about CMS’s accountable health communities model.