The Atrómitos Way

#054: Innovations on the Ground: Building a Social Care Network

February 27
53 mins

Episode Description

Healthcare often focuses on clinical symptoms and medical treatments, while many patients lack essential support for non-medical factors which greatly affect health outcomes. Social care networks aim to connect healthcare providers with community-based organizations to address the social determinants of health, such as housing stability, food security, transportation, and access to medical care.

From early 2022 to mid 2025, Community Care Lower Cape Fear (or CCLCF) saw firsthand what coordinated care can accomplish—and what happens when funding disappears overnight. On today’s episode, Atrómitos president, founder, and CEO Michealle Gady speaks with two leaders at CCLCF who are driving the efforts to build a robust and sustainable social care network with a new grant from the New Hanover Community Endowment.

Michealle Gady has more than 20 years of experience helping health and human service providers, government agencies, advocates, and philanthropies create lasting community change.

Sarah Ridout, MBA, SPHR is the Director of Community Programs for Community Care of the Lower Cape Fear (CCLCF) where she focuses on planning, implementation and program oversight of community programs within southeastern NC. 

Dr. Michelle Jones has practiced Family Medicine in the Wilmington, NC area for over 26 years. She is a Past President of the North Carolina Academy of Family Physicians and has served as Medical Director of Community Care of the Lower Cape Fear for the last 5 years.

Key Takeaways

What happened? From pure cost savings, to a reduction in emergency department visits, to improved health outcomes, the HOP pilot had significant positive outcomes.
Who benefited? Those outcomes weren’t limited to direct recipients. Every member served by the HOP pilot touched at least two lives, and most services supported whole households.
What’s next? As CCLCF looks to the future to build a new social care network—one which aims to outlast any single funding source—what lessons can be learned from the HOP pilot?

Want to learn more about CCLCF and the Social Care Network Initiative? Visit their website at carelcf.org. If you're interested in supporting this work, reach out to CCLCF directly at info@carelcf.org.

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