Cedars-Sinai Blog
Inspiring Community Health by Meeting Patients’ Needs
Understanding barriers to a person’s wellbeing is critical to their healthcare plan.
A diabetic patient who can’t regularly cook or afford groceries will likely also struggle sticking to the fresh, low-carb and low-sodium diet needed to control their blood sugar. Another patient’s chronic stress about keeping the lights on may lead to or worsen their high blood pressure. And social isolation in older adults is linked to mental health risks, dementia, heart disease and even an earlier death.
What if social support could guide patients toward lasting solutions?
"Many patients require services, but because they’re so used to being turned away or told there are no resources, they decline help," said Caroline Carbajal, a senior community health worker with Cedars-Sinai's Community Connect Program. "It’s a recurring problem. They slip through the cracks."
"Motivational interviewing is about how we move together toward the same thing, not letting anybody have too much power over the process."
Forging Community Healing
Cedars-Sinai Medical Center began screening every admitted patient for social drivers of health in 2024, considering access to food, housing, transportation and utilities as well as exposure to physical or emotional violence. Hospital staff dig deeper into isolation, health literacy, cost of care, drug use and other conditions compromising patients’ health and ability to live independently.
Community Connect rolls out a safety net for vulnerable patients. Community health workers usher often-overwhelmed patients through the fragmented system of more than 100 state, county and nonprofit programs—and waitlists—to provide the patients with resources. Typically paired with 15 to 20 patients for six weeks, Community Connect workers apply and make persistent calls to secure meals, rides to doctor appointments, health coverage, long-term healthcare or housing for the patients.
When patients are misinformed or someone wrongly denies their application, Carbajal says Community Connect workers push back.
"It starts with communication," she said.
Community Connect swiftly expanded from just three health workers during its 2021 launch to 10 by 2024, ramping up their support with a series of trainings.
Motivating Action
Motivational interviewing is one tool health workers—and anyone—can use to get to the bottom of why a person isn’t seeing progress with their health.
A widely adopted and growing framework, motivational interviewing centers on:
- An open-ended format
- A “conversation sandwich”: asking what a patient already knows about the subject (such as nutrition, disability, substance use counseling or assisted living), then asking to share resources, and closing with a question reviewing the patient’s feelings
- Active listening skills, including echoing and affirming thoughts to ensure patients feel understood
- Determining and supporting the patient’s goals
- Respect for the patient’s boundaries, such as a refusal to discuss certain care options
Cedars-Sinai community health supervisor Olivia Cerna compared it to a dance.
"Motivational interviewing is about how we move together toward the same thing, not letting anybody have too much power over the process," she emphasized.
That foundation empowers Community Connect workers, who studied the technique, to confront core challenges that are at the heart of a patient’s social needs. For example, they might tackle an older adult’s fear of leaving their house with a walker after a serious fall. That can lead the patient into an adult day services program or to an activity at a community center for older adults, overcoming the isolation and depression that had been creeping in when they were housebound.
Carbajal also uses the approach with community members whose immigration status and language barriers make it difficult for them to navigate their healthcare. Through her conversations, she explains to patients that they might be eligible for health insurance and, despite widespread misconceptions, applying won’t risk their immigration cases.
"I educate people about the healthcare system and benefits, encouraging them to not give up," she said. "That way, they can advocate for themselves and their own health in the future."
You can use motivational interviewing to investigate any behaviors, including smoking, vaccination and avoiding important calls. Experts stress the importance of asking for permission before broaching these conversations with a loved one or offering resources.
Self-Care for Sustenance
Community Connect also trains health workers on remembering to care for themselves. All caregivers are at risk of burnout and should prioritize eating three meals a day for energy, sleeping seven to eight hours a night and finding outlets to release tough emotions.
Behavioral activation works similarly. The skill, which can be used in tandem with motivational interviewing, seeks to reinvigorate people whose mental and physical health causes disinterest. People who have been trained in the therapeutic technique can help others schedule walks, music or other mood-boosting activities throughout their day. Cedars-Sinai researchers have found the practice is as effective as antidepressants in heart disease patients.
Catching Patients Before a Fall
On top of health worries, a hospital stay often threatens the financial security of working families. Cedars-Sinai’s partnership with Los Angeles nonprofit The Change Reaction is stepping in as a stopgap.
The initiative, launched in 2022, provides up to $599 in financial assistance for a patient and their family in immediate need.
"Life throws curveballs at you," said Wade Trimmer, president of The Change Reaction. "We don’t think you should have to fall to the bottom of the mountain to get help. Let’s just shore you up where you are so you can keep on climbing."
Supporting the Whole Person
Social workers and community health workers collaborate with The Change Reaction to identify patients whose illness or accident puts them at risk of eviction or financial crisis. Through gift cards providing direct relief—including rent and transportation assistance, hospital parking, lost income and essential home repairs—the partnership empowers Cedars-Sinai staff to have open conversations with patients.
"Everyone is different, so we really need to listen to what matters most to the patient and what they need to stay healthy," said Cedars-Sinai social worker Sari Steinberg.
She said the funds provide a vital tool for workers who otherwise would have no urgent solutions for a patient facing homelessness or running out of medication, instead waiting a month or two for public services to kick in.
The support extends beyond hospital walls, easing patients’ stress and social and economic barriers, such as inconsistent access to nutritious food, to help them heal faster.
It adds a new level of fulfillment for hospital staff, too, who know they are making a meaningful difference in patients’ lives.
"We see what they’re up against," Trimmer said. "This relief lifts the spirits of both patients and frontline workers. It’s transformative."
