CHI Lisbon Health, a member of CommonSpirit Health, is advancing its Total Health Roadmap initiative to improve patient outcomes by addressing social drivers of health (SDoH)social determinants of health. Through universal screening in primary care and the integration of Community Health Workers (CHWs), the program is designed to identify health-related social needs and connect individuals to essential resources.
The Roadmap’s expansion in North Dakota and Minnesota builds upon lessons learned from early implementations in other communities. By tailoring best practices to diverse rural populations, the initiative aims to bolster health care accessibility while complementing ongoing developments in telehealth and patient-centered medical home models.
At its core, the Roadmap seeks to bridge clinical care with community health outreach, ensuring patients receive comprehensive support to overcome challenges related to social drivers of health determinants. This includes socioeconomic factors that significantly impact health outcomes — such as housing, food security and employment stability.
“Serving as a Community Health Worker allows me to connect with new individuals and assist those within our community,” said Rebecca Nord, who works as a Community Health Worker Advocate at CHI Lisbon Health. “The sense of fulfillment I experience when I am able to aid someone is the most rewarding aspect of my profession. Whether I am guiding someone through the application process for a government assistance program or simply helping them order their medical supplies online with insurance to save them some money.”
Nord emphasized the versatility of a CHW’s role in supporting individuals.
“The responsibilities of a Community Health Worker encompass a broad range of practices. However, the essence of this role is to assist you,” Nord said. “While I may not possess all the answers, I am committed to putting in the effort to support anyone who seeks assistance. I am here to provide support to those in need.”
CHI Lisbon recently introduced the CHW role, making it easier for residents to access community-based assistance.
“The opportunities this role presents are not entirely unprecedented, but they are now more accessible than ever before,” Nord said. She noted the Ransom and Sargent County Coalition’s has been working on developing a Community Health and Wellness Guide. “This guidebook encompasses all the community resources we could gather, including senior services, housing, social services, veterans services and much more.”
CommonSpirit’s Roadmap is aligned with national initiatives, including the CMS Accountable Health Community model, which emphasizes the role of primary care in identifying and addressing social needs. The organization is also guided by recommendations from the National Academies for Integrating Social Care into Health Care.
To create lasting impact, CommonSpirit is investing in technology-driven solutions that facilitate better collaboration between health systems, government agencies, and local community organizations. The Roadmap aims to improve screening and referral practices by ensuring equitable access to care, regardless of insurance coverage or socioeconomic status.
Through these efforts, CommonSpirit Health is shifting the health care landscape to prioritize patient-centered solutions. Universal screening and CHW integration provide insight into barriers affecting patients and their families, while strengthening partnerships with local organizations and improving referral systems.
The initiative also incorporates a long-term evaluation strategy that tracks patient outcomes, health care system changes, and opportunities for continued learning.
“We are working to adjust the lens through which our national and local care delivery systems view sustainability,” Nord said. “Rather than focusing solely on traditional return-on-investment metrics, the organization aims to include stronger measures of care delivery improvements and contributions to health equity.”
As the Total Health Roadmap expands, the initiative underscores CHI Lisbon Health’s commitment to ensuring every individual has the opportunity to live the healthiest life possible. By integrating social care into health care, fostering collaboration and strengthening the continuum of services, the organization is shaping a more effective and equitable system for future generations.