The community weaver role was designed as part of Eskenazi Health’s efforts to help Indianapolis residents combat obstacles to social determinants of health (SDOH), factors aside from clinical care — safety, access to healthy food, job opportunities, etc. —believed to determine 80% of individuals’ health. Community weavers are empowered to aid residents in all neighborhoods with Eskenazi Health Center locations, with an emphasis on three health equity zones (HEZs), communities Eskenazi Health has identified as facing a 16-year lower life expectancy than those in more advantaged Indianapolis-area neighborhoods. Community weavers identify residents’ SDOH needs, build relationships with the organizations that answer those needs and perform outreach where residents congregate.
Happily married for 15 years now with “two wonderful boys,” Community Weaver Renee Alford describes the neighborhood where she grew up in South Bend, Indiana as like those in the HEZs she now assists. Before joining Eskenazi Health, Alford spent more than 10 years in elder care and earned a master’s degree in gerontology.
Community weavers like herself, says Alford, have “just an array of backgrounds.” They can profit from one another’s expertise in areas such as the transportation industry, mental health, unhoused populations and older adult communities. “We lean on each other quite a bit,” says Alford. “If we do make connections or we do find resources, we tend to share them immediately with one another.”
Eskenazi Health’s community health workers and social workers are too busy working with patients at an Eskenazi Health Center location to attend many community outreach events or to develop relationships with the organizations they will need if their patients screen as food or transportation insecure. That’s when community weavers step in.
Once patient needs are assessed through weekly meetings with Eskenazi Health social workers and community health workers, community weavers link their team members to the relevant community resources. The community weavers have already identified the names of people leading programs and organizations “so [that] our team doesn’t have to go through all that red tape . . .” With such relationships, the team can skip preliminaries and talk directly to a neighborhood organization about a patient. “It really does work,” says Alford.
For example, weavers have ties to the Salvation Army, Horizon House and the Street Outreach Animal Response (SOAR) Initiative, which assists unhoused locals unwilling to leave their pets, even in medical emergencies. Another weaver relationship is with the Grassroots Projects, an organization that provides care packages for immigrants, which include clothing and car seats.
Outreach events are opportunities to inform residents about such critical resources. Community weavers go to schools, libraries, neighborhood centers and even laundromats, explaining services and assisting anyone who approaches them with difficulties scheduling a medical appointment or with SDOH concerns. Alford says frequent resident obstacles include struggles with food, employment, transportation, housing, mental health and school uniform costs. Community weavers connect patients and nonpatients with the organizations that can assist.
One SDOH issue can spiral into many more. “We have people that need help with rental assistance,” explains Alford. “A community weaver will talk to them a little more, dig a little more — they ask permission if they can dig a little more — and we find that there’s a whole story there . . . . ”
Alford describes a man in his sixties who asked for a month of rental assistance. A caregiver to his disabled wife, he couldn’t pay rent or utilities and still provide her with care. This was a “classic example” of what community weavers encounter, says Alford. A community weaver connected his spouse to CICOA Aging & In-Home Solutions for home health aid while connecting him with social security benefits and with Goodwill’s Senior Community Service Employment Program (SCSEP).
“We just hear these wonderful stories. That one always has sat with me,” she says, “because it was just so many layers. That one issue caused a domino effect.”
Last spring Alford, then the community weavers’ supervisor, was honored along with her team as finalists for the Indiana Business Journal’s Health Care Heroes award. While Alford enjoyed her leadership position, she decided this year to return to the community weaver role at Eskenazi Health Center West 38th Street, where she could be more immersed in the SDOH work she loves.
She loves brainstorming with social workers and community health workers to resolve a problem. “It’s always a reward,” Alford says, “when there’s a crisis, and I can figure out how to help. It’s just amazing.”