May 9, 2025
At Blooming Day 2025, one of the most anticipated panels brought together three trailblazing leaders redefining how health systems address social needs, not just as an add-on, but as a core part of care delivery.
Moderated by Blooming Health’s Co-Founder and Chief Commercial Officer Kavitha Gnanasambandan, the session "Healthcare Meets Social Care" offered a powerful, real-world look at how major health systems are screening for social needs, making referrals to community-based organizations (CBOs), and building the infrastructure to truly close the loop.
Panelists included:
Dr. Patrick Runnels, CMO, University Hospitals
Alisahah Jackson, MD, President, Lloyd Dean Institute for Humankindness and Health Justice at CommonSpirit Health
Nicole Harris-Hollingsworth, Senior Vice President, Social Determinants & Social Impact, Hackensack Meridian Health
From Concept to Scale: Social Needs Screening in Action
Dr. Alisahah Jackson, President of the Lloyd H. Dean Institute for Humankindness and Health Justice at CommonSpirit Health, kicked off the conversation with a reminder of scale and nuance. Serving over 12 million patient visits a year across 24 states, CommonSpirit is deploying multiple care models tailored to local needs—from Kentucky to California. But the throughline is clear. Integrating social care across the full continuum, supported by standardized data collection and community input.
“In this work, there is no one-size-fits-all,” said Dr. Jackson. “We need to listen to our patients, our providers, and our CBO partners—and meet each community where they are.”
Hackensack Meridian Health’s Nicole Harris-Hollingsworth shared a candid story of starting small and smart. “We began with the wrong population for the right reason,” she said, explaining how a pilot focused on a lower-risk group allowed them to prove their model’s impact before scaling. Four years later, the system has completed over 1.8 million screenings and made more than 5 million connections to services, supported by 120 community health workers and 750 care coordination staff.
Closing the Referral Loop Isn’t Easy—But It’s Essential
Dr. Patrick Runnels, Chief Medical Officer for Population Health at University Hospitals, pulled back the curtain on what happens after screening—and why getting people connected to resources is still one of the biggest pain points.
“You can have someone check a box for food insecurity, but that doesn’t mean they want or need help,” he noted. “There’s a human interaction needed to sort that out—and that creates a major bottleneck.”
The solution? Technology, people power, and smart triage. Runnels emphasized the need to prioritize high-risk patients, build strong CBO partnerships, and use AI to lighten the load on care teams so they can focus on what really matters: relationships.
Strengthening Community Partnerships
Every panelist agreed—CBOs are not just endpoints. They are essential partners.
“We’re investing millions through our Community Investment Fund and being more intentional about where that money goes,” said Dr. Jackson. “If housing is the top-identified need in a region, our funding strategy should reflect that.”
Nicole Harris-Hollingsworth shared that at Hackensack Meridian, the philosophy is clear: don’t duplicate what already exists in the community. Instead, amplify, advocate, or—only when needed—build with a plan to hand it off. One example? A SNAP-access program that doesn’t require patients to be part of their health system but still improves healthy food access statewide.
What Role Should AI Play in Social Care?
As the panel wrapped, Kavitha posed a critical question: "What’s the role of automation and AI in all of this?"
For Dr. Jackson, it’s about using AI as a tool to reconnect with our shared humanity. “We’re more digitally connected than ever—but also more isolated. Can we use AI to restore empathy, kindness, and community connection in healthcare?”
Dr. Runnels agreed, highlighting how AI can help unburden care teams from administrative tasks and free them to focus on meaningful human relationships.
And Harris-Hollingsworth offered a thoughtful caution: “We must balance what we can do with what we should do. AI should create pathways for more community members to engage, not replace them.”
There’s no shortcut to this work, but there is a path forward. It’s one paved with community, data, and intentional partnerships.
Blooming Health’s platform continues to evolve, using inclusive AI and automated outreach to streamline referrals and support CBO growth. We’re proud to walk that path alongside the trailblazers shaping the future of care.
Contact us to learn how we are supporting social care and healthcare organizations.
