CHI Oakes Hospital, 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.
“I’ve had the privilege of working as a CHW in the Oakes community for almost a year now, serving as an intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery,” said Beth Brademeyer, who works as a Community Health Worker Advocate at CHI Oakes Hospital. “Basically, I help with social determinants outside of the clinic that may affect health, such as food, housing, transportation, safety and financial needs. Having these basic needs met is an essential part of staying healthy.”
Brademeyer 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,” she 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 Oakes recently introduced the CHW role, making it easier for residents to access community-based assistance.
“We are fortunate in Oakes to have a caring community willing to help those in need,” Bradenmyer said. “Wondering where your next meal will come from — if you will be able to afford rent and utilities, etc. — can be extremely stressful and take a huge toll on your well-being. Being able to let people know there are people who care and can help, and relieving that burden for them, is the most satisfying part of my job. One small step in helping someone can change their lives for the better and I am grateful to be a part of that.”
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,” Brademeyer 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 Oakes Hospital’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.