Essential health information from local experts

Treating the Whole Person

Connecting patients with community resources to promote health and wellness

Maintaining good health doesn’t start—or end—at the hospital.

“Research shows that 80% of a person’s health is impacted by what happens outside the hospital walls,” says Mary O’Connor, MSN, RN, manager of Community Health at Sarasota Memorial. “Because if you aren’t able to meet the basic needs in your life, you won’t be able to maintain a healthy body and mind.”

Everyday needs that can affect people’s ability to maintain their health include:

Housing: Does the person have a stable place to live?
Food: Does the person have regular access to nutritious food that promotes health, not just fast food and junk food?
Transportation: Does the person have a reliable means of traveling to doctor’s appointments, the grocery story, church, or work?
Utilities: Does the person have access to running water, electricity, heat, and/or air conditioning?
Safety: Is the person in relationships where they are verbally, emotionally or physically harmed?

If even one of these needs is not met, that individual’s ability to prioritize and proactively take care of their personal health can be seriously diminished. After all, it’s hard to manage your diabetes, when you don’t know where tomorrow’s meal is coming from, let alone how to pay for those necessary medications.

“At Sarasota Memorial, we go one step above by looking for root causes to health issues and examine the non-medical factors that can be contributing to disease,” O’Connor says. “Because if you really want to help a patient, you have to look at the whole person.” SMH Manager of Community Health Mary O’Connor, MSN, RN

“If we ask people what their challenges are,” she continues, “we can give them a little extra help that may lead to better health outcomes and fewer visits to the hospital.”

A Comprehensive Approach

Social case workers at Sarasota Memorial have long been going that extra mile to help address patients’ post-discharge needs. And a new screening process implemented in 2024 is already showing incredible results, says O’Connor.

“The screening happens at admission,” she says, “which allows us to identify patients’ basic needs early, and we can start working on connecting them to available resources before they leave the hospital.”

Instead of relying strictly on social case workers to screen patients for social needs, every nurse admitting patients at Sarasota Memorial now asks these questions. Based on the patient’s answers, a social worker will meet with the patient to talk about connecting them to available community resources that can help.

Community-Centered Care Yields Community Impact

Within five months of instituting a system-wide screening to identify patients’ everyday needs that can impact their health, Sarasota Memorial social workers saw a 67% increase in the number of patients being identified with needs and connected to essential community resources.

“And we already know it reduces readmission to the hospital,” O’Connor says.

Where Are These Community Resources?

Sarasota is home to numerous community-minded nonprofits and organizations looking to help those in need. The problem, however, can be finding them and determining what services they offer.

“It’s important for each organization to know who their community partners serve and what programs they provide. Our goal is to eliminate siloes, so organizations can share information and work together to improve the coordination of care for the community members we all serve,” O’Connor says.

Enter Unite Us, an online platform that serves like a giant directory for community resources in the area. Through Unite Us, organizations like All Faiths Food Bank, First 1,000 Days, Salvation Army, Healthy Start Coalition, Meals on Wheels Sarasota, Mothers Helping Mothers, Senior Friendship Centers, Sarasota Medical Pregnancy Center, various veterans and behavioral health programs, all sorts of faith-based nonprofits, and more—including Sarasota Memorial—can connect and coordinate care and resources for people in need.

“Physical environment, education, job status, family support, lack of transportation or food — all of these things impact a person’s health,” O’Connor says, “Even the best healthcare systems can only do so much to improve outcomes if those needs aren’t recognized.”

Community Resources In Your Area

Curious about what’s available near you? Visit Sarasota Memorial’s Unite Us portal and enter your address to view resources in your area.

NOTE: Many organizations listed on Unite Us require a referral for services.