“Would you like help finding transportation to clinic appointments? Paying your utility bills? Feeding your family?” These might not be questions patients expect to be asked at a doctor’s visit, but thanks to Hopkins Community Connection (HCC), these questions are not only being asked, they’re a catalyst for overcoming obstacles.

Formerly known as Health Leads™, HCC works to identify and address patients’ essential social needs and connect them with the basic resources they need to be healthy. These social determinants of health –– which can range from access to healthy food, safe housing and education to safe neighborhoods and freedom from discrimination –– can directly impact patients’ health, putting them at greater risk for chronic illnesses like diabetes, cardiovascular disease and asthma.

“We really serve the whole health picture, not just of the patient, but of the family,” says Kristin Topel, Hopkins Community Connection’s program manager. “Families could have questions about their insurance, where to get food or how to get the lights back on. And, no matter who they ask, they’ll be connected to a resource to solve the problem.”

To that end, undergraduate students from The Johns Hopkins University volunteer their time to staff resource desks at the Harriet Lane Clinic, Johns Hopkins Bayview Children’s Medical Practice and Hopkins Bayview Comprehensive Care Practice. Students typically carry a caseload of about 10 families, with whom they personally follow up regularly to continually assess their needs.

“Our program is very trustworthy and it’s because of the incredible relationships our advocates are able to build with patients and their families,” says Sarah Hill, a program coordinator at the Harriet Lane Clinic, who joined HCC as an undergraduate volunteer.

What would happen to the 3,000+ families receiving HCC services each year if the program dissolved? That almost happened in June 2019, when a change in national funding resources threatened the future of HCC. Recognizing the potential distress to families, the team immediately sought private funding.

Enter the Straus Foundation, which supported the program at its inception nearly 14 years ago, under Barry Solomon’s leadership as the then-medical director of the Harriet Lane Clinic. The Straus Foundation aims to understand the barriers underserved populations face, and funds programs that help to overcome these obstacles, says Solomon, now chief of the Division of General Pediatrics. When he reached out to Jan Rivitz, the Foundation’s president, she knew they needed to help. 

“We have this world-class institution sitting in one of the most under-resourced neighborhoods in the country, and any effort we can make to connect those two just makes sense,” Rivitz says. “We believe in taking the kind of calculated risks that others don’t. If philanthropy doesn’t, who will?”

Thanks to ongoing financial support from The Johns Hopkins Health System, with additional support from the Straus Foundation and other funders, including Rite Aid and Morgan Stanley, Hopkins Community Connection is funded through 2021 –– and none too soon. While the program typically helps 400 families at a time, the needs exacerbated by the COVID-19 pandemic have skyrocketed enrollments. Currently, HCC is actively helping nearly 850 families to combat food insecurity and to provide access to basic necessities, such as infant formula and diapers.

“Our program offers a connection to those resources that families often don’t know they’re eligible for or may not know how to access,” Solomon says.

The HCC team has expanded to include community health workers and social work trainees, helping them to address more complex social needs and conduct home visits. HCC has also hired employment specialists who assist with resumes and job applications, and created a new on-site food assistance program supporting families and essential health care workers facing financial hardship.

“We really wouldn’t be operational without funders like the Straus Foundation,” says Hill. “It’s incredible to have people who recognize that this is impacting some of the most vulnerable families in Baltimore.”

To support the Hopkins Community Connection program, email [email protected].