The future of health care has to do with social connection

How one community organization partnered with a local hospital to improve patient outcomes 

This article is based on a webinar presented by Kate Hoepke and Jessica Da Silva of San Francisco Village. Click here to see the webinar!


The leading factors impacting longevity are not what most would expect, things like exercise or smoking or obesity. Instead, research has found that the top risk factors for mortality are social in nature, whether someone has close relationships or has a sense of belonging. It’s why one San Francisco Village board member and former hospital operations executive says, “I am convinced that the future of health care has to do with social connection and addressing loneliness.” 

Community organizations offer valuable services that are of interest to healthcare systems looking for ways to improve patient experience and outcomes. San Francisco Village is one such community organization that forged a partnership with their local hospital system to deliver social care services for patients transitioning from hospital to home, achieving superior patient outcomes on hospital readmission rates. 

About San Francisco Village: 

Established in 2009, San Francisco Village is a community organization that operates at the intersection of health care and social care. It is a nonprofit membership organization that connects older San Franciscans to the community, resources and expertise they need to live independently in the places they call home. The fundamental purpose is to build relationships, accomplished through social, educational programs; volunteer services; neighborhood circles; and other resources and referrals. Over 200 multi-generational volunteers support members with a host of services like transportation, help around the house, friendly visits, grocery runs, and other types of support.   

Why would a hospital partner with a local nonprofit? 

Sutter Health’s California Pacific Medical Center (CPMC) is one of the major hospital systems in San Francisco. CPMC’s collaboration with San Francisco Village was developed upon the opening of a new hospital in San Francisco in 2019 to support connection with the neighboring community.

At the time of opening, CPMC was looking for community organizations to partner with because, as San Francisco Village also hypothesized, recently discharged patients are more likely to successfully transition to home when they have social care and support.

CPMC had a clear goal to reduce 30-day hospital readmissions, and their data told them readmissions were driven by a number of non-medical factors, including lack of transportation for follow-up appointments and not having medications on-hand. Well, giving rides and helping run errands are two things that San Francisco Village already did through their volunteer services model. They knew that where CPMC can deliver high-quality health care to patients, San Francisco could help facilitate community support once patients are discharged so they can successfully transition to a home setting.


Pursuing the partnership 

Under the leadership of executive director Kate Hoepke, San Francisco Village pursued and designed a partnership with CPMC through their own trial and error. They share a few key takeaways for community organizations exploring such a partnership: 

Be clear about the mutual value proposition: 

San Francisco Village figured out early on what the need of the hospital was and what the value proposition would be to the hospital, in addition to the value such a partnership would bring to their own organization. In learning that two of the major risk factors for readmission were transportation and prescription fulfillment, they could orient their pitch to offer a practical solution with their existing services. In addition to the primary goal of reducing readmissions, the secondary outcomes San Francisco could advance were preventing ER visits, decreasing isolation and loneliness, and increasing community engagement. 

Figure out who the decision makers are: 

Many partnership conversations never get off the ground because the decision makers aren’t at the table. San Francisco Village knew from prior experience that their connections with social workers, nurses, or other hospital staff would not be enough; they needed executive buy-in. Through an introduction from a mutual donor, San Francisco Village connected with the CEO of CPMC, but as the saying goes, “Luck is what happens when preparation meets opportunity.” Hoepke followed up for a coffee chat and shared her vision for how the village model could optimize health and well-being and work in conjunction with CPMC. The CEO’s buy-in was step one in a lengthy process but a critical ingredient. 

Ask for what you need (dollars and resources) in order to deliver: 

With a small but mighty staff of six, San Francisco Village knew that they would need a newly dedicated staff member to manage the partnership, build relationships, and handle client referrals. They budgeted and negotiated for funding from Sutter Foundation, 80% of which would pay for the hiring of a full-time staff member who would coordinate the partnership. 

Managing the partnership

In the days before discharge from CPMC’s ACE Unit, patients who may benefit from membership in San Francisco Village services are educated on the program’s services. A wellness coordinator calls or visits ACE patients in the hospital to enroll them in San Francisco Village and connect them to its services at no cost. These services help patients stay healthy at home, and they are encouraged to continue their membership with San Francisco Village after their recovery.

San Francisco Village brought on Jessica Da Silva, MPA, as a Wellness Program Coordinator to launch and manage the partnership with CPMC. She saw her role as fulfilling several key responsibilities: 

  • Build strong relationships with hospital staff and learn their language: Once the contract was signed, San Francisco Village knew that the most important role of the Coordinator was to build relationships with key members of hospital staff who would be vital to the success of the program. To that end, Da Silva showed up at the hospital multiple times a week and attended weekly medical rounds to learn their language and how they work. It was important that hospital staff including doctors, nurses, and social workers know who she was and what San Francisco Village did, and showing up consistently was the best way to do that.
  • Workflow: The Wellness Program Coordinator needed to design from end-to-end how the patients would experience the transition from hospital to home with San Francisco’s Villages. How will referrals and handoffs work? How does intake and assessment work? Who needs to be involved at what stages? 
  • Documentation: Gathering and keeping track of everything from reporting requested from the hospital to all the data San Francisco Village would be receiving through the course of service delivery. In addition, creating all the consent forms, intake forms, and outreach letters to patients and providers. 
  • Volunteer outreach strategy: A key component of the partnership was services delivered by volunteers, so the Wellness Program Coordinator recruited and conducted outreach in the community to identify motivated and responsible volunteers to support the patients in the program. They found that college students in health related fields were especially eager to volunteer and gain exposure to supporting older adults in a care setting. (See “Tips for recruiting college age volunteers for senior services”). 
  • Marketing materials: Created to be used in the hospital with potential or new patients and within the community to let people know about the new partnership 

Outcomes of the partnership 

After just a couple of years, the partnership is already demonstrating an impact. In preliminary findings, patients who are enrolled in the program are four times less likely to be readmitted within a 90-day period than similar patients in a control group who are not enrolled in the program. San Francisco Village and CPMC are working with researchers to publish these findings. 

In addition, those patients enrolled in the program have more comorbidities than other patients discharged from the hospital, demonstrating the program’s benefit to patients who have higher needs and may be less independent. Finally, patients in the program were more likely to be living alone, a finding that was important to San Francisco Village which aims to provide connection and community to those who need it most.  

How San Francisco Village partnered with Mon Ami 

Mon Ami worked with San Francisco Village to implement a technology system that would streamline its operations and improve data collection and reporting. A rigorous documentation system was essential to the partnership with CPMC, with numerous forms and outputs to track for service delivery. 
“San Francisco Village needed an operating system to manage our partnership with CPMC. And with Mon Ami’s technology, we can focus on what we do best, the relationship building and the human elements, while the technology streamlines so much of what we need to do.” 

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