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Patient Portals

Addressing Our Patient's Social Needs

Family outdoors smiling

Non-medical healthcare problems need attention, too.

Many community members struggle to maintain healthy behaviors and/or keep up with their medical care because of barriers such as transportation, childcare, or affordable housing, food, and medications. This is where Social Care can make a difference. Social Care supports a person’s overall health and well-being. Through programs like the National Diabetes Prevention Program and Community Health Worker Hub, Social Care helps the people we serve –patients, colleagues, and community members- get access to food, housing, health care, and other social services needed to stay healthy. 

Trinity Health’s Community Health Worker (CHW) Hub is a network of CHWs and community-based organizations that work together to support individuals and families in need. Our CHWs represent the communities they serve and are a bridge between health and social services, and the community. Through their lived experiences, CHWs work closely with a patient to assess their social needs, home environment, and other risk factors and ultimately connect patients to services within the community. 

Additionally, we've created the Trinity Health Community Resource Directory, which is an online portal connecting those in need to free or reduced-cost health and social service resources within the community and across all Trinity Health locations. We invite everyone we serve, our colleagues and community members to access the Community Resource Directory by visiting https://communityresources.trinity-health.org/.

Examples of Social Care services we offer or can make available for referral (as available locally – not available everywhere) include:

  • Behavioral Health (peer support, substance use treatment, mental health)
  • Benefit Enrollment Support (unemployment, Medicaid, and/or SNAP)
  • Diabetes Prevention Program
  • Financial Assistance
  • Food Assistance
  • Primary Care for the uninsured/and or Medicaid Population
  • Low/no cost medications or medication delivery for persons unable to leave their home
  • Shelter (temporary placement or longer-term supported housing or permanent placement)
  • Social Isolation programs
  • Tobacco Cessation
  • Transportation Assistance