San Francisco Bay area-based Contra Costa Regional Medical Center and Health Centers is reinventing  its care delivery by partnering with a service provider called Health Leads to send patients to resources that address their health in a broad way, such as food and housing.

The hospital’s CEO, Anna Roth, R.N., told NEJM Catalyst about how the program works for her hospital system as part of its move toward value-based care.

“It is time we look beyond the four walls of our institutions and see how we can partner with those who have already mastered things like housing and employment…..{M}aybe the role we can play is to be strong partners for them so they can strengthen themselves.”

The Centers for Medicare and Medicaid Services   will spend as much as  $147 million in grant money starting this fall to help fund similar partnerships under a new Accountable Health Communities (AHC) model that will screen Medicare and Medicaid recipients for health-related social needs. Bridge organizations will screen and refer patients to clinical and community services.