How Trinity Health Reduced Preventable Hospitalizations by 41%
Healthcare often happens outside the doctor’s office. A person’s access to food, housing, and social support has a major impact on their well-being. But too often, clinical care and social care are disconnected. This makes it hard for patients to get the help they need to stay healthy and often leads to preventable hospitalizations.
Patients dually enrolled in Medicare and Medicaid face some of the biggest hurdles. Trinity Health noticed that these patients had a preventable hospitalization rate more than double that of their general patient population. They decided to take action to fix this disparity.
We partnered with Trinity Health to build a system that seamlessly connects patients to community resources. By embedding Community Health Workers (CHWs) into their clinical teams and using Findhelp’s platform, Trinity Health achieved a 41% decrease in preventable hospitalizations for their dually-enrolled patients.
In this post, you’ll learn:
How Trinity Health integrated CHWs into clinical care teams
Ways to use technology to close the gap between medical and social care
Real-world results showing a massive drop in preventable hospitalizations for vulnerable patients
Bridging the gap with community health workers
Trinity Health knew that preventable hospitalizations—like admissions for heart failure or diabetes—could be managed with the right outpatient support. Because heart failure was the leading driver of these hospitalizations, they integrated CHWs directly into care teams alongside nurse managers, social workers, and pharmacists.
Instead of keeping CHWs in an isolated department, Trinity Health made them a central part of the care plan. These workers visited patients in their homes to find out what basic needs were missing. They screened for social needs and provided everyday tools, like scales and pillboxes, to help patients manage chronic conditions safely at home.
Systematizing social care with Findhelp
To give CHWs the support they needed, Trinity Health integrated Findhelp directly into their electronic health record, Epic. This integration gave staff members immediate access to our network of free and reduced-cost social services. When a team member screened a patient, they could search by ZIP code and add relevant local programs to the patient’s after-visit summary.
Maureen Pike from Trinity Health explained how important it was to organize this information to empower their teams:
“But Findhelp takes all of that knowledge out of people’s brains and puts it in a searchable place, and this has been helpful on several levels. One, you know, we love to systematize. We love to scale at Trinity Health. This is scalable. This is something that can be and is available throughout our entire system.”
Maureen Pike | MPH, MBA, RN
Former Director, Clinical and Social Care Integration at Trinity Health
This setup allows navigators to match patients with meal delivery, housing support, and transportation quickly. It also makes it easy for patients to self-navigate if they want to look for resources on their own.
Seeing real results for patients
The success of this integrated approach is visible in both the data and individual patient stories. As detailed in our recent Trinity Health case study, they achieved:
41% Decrease
In preventable hospitalizations for dual Medicare/Medicaid patients from FY22 to FY25
58% Decrease
In preventable hospitalizations disparity between Medicare and dual Medicare/Medicaid patients FY22 to FY25
$28.2 Million
In Medicare shared savings in calendar year 2023
The impact goes far beyond the numbers. During a 2025 Becker’s Healthcare webinar with Findhelp, Maureen shared Miguel’s story to illustrate the impact of integrating social care and clinical care.
ONE PATIENT’S STORY
Miguel is a 49-year-old patient with heart failure. He lived alone and felt overwhelmed. Trinity Health referred him to a CHW who visited his home. The CHW gave him a scale and a pillbox, and used Findhelp to connect him to heart-healthy meal delivery and housekeeping services. Soon, Miguel’s missed appointments dropped by 90%. He started cardiac rehab and nutrition classes, taking control of his health.
Connecting health and social care for good
Trinity Health proves that when care teams have the right tools, they can improve lives and reduce hospital visits. By prioritizing social needs, health systems can actively support their most vulnerable communities. We are proud to provide the platform that helps customers make these essential connections.
“Within this clinically integrated network, we have to look at patients’ social needs and their social circumstances and how that is affecting care plans, to be able to have their basic needs met every day… It’s not only in the value-based environment, but there’s definitely a great case for it when you’re trying to really comprehensively serve a patient.”
Maureen Pike | MPH, MBA, RN
Former Director, Clinical and Social Care Integration at Trinity Health
If a health system wants to build stronger, healthier communities, integrating social care into clinical workflows is the best place to start.
