This session explores how two care delivery teams are transforming health outcomes by embedding social drivers of health (SDOH) into clinical workflows and community partnerships. One initiative redesigned screening and referral processes to address food, housing, transportation, and utility needs across all patients, not just those covered by reimbursement policies. Another implemented a team-based diabetes care model that integrates inpatient, outpatient, and community services, while addressing SDOH barriers through coordinated care and education.

Attendees will learn how to build sustainable, data-informed strategies that improve care coordination, reduce disparities, and strengthen community connections—ultimately creating more equitable and effective healthcare systems.