UNC Family Medicine will lead a new effort to improve care for patients with complex health and social needs, following a $1.3 million grant from The Duke Endowment to the UNC School of Medicine and UNC Health.
The funding will support the Bridge to Health initiative, a pilot program designed to expand hospital-based transitional clinics and strengthen partnerships between health systems, primary care providers, and community organizations.
Led at UNC by Timothy Daaleman, DO, MPH, a professor of family medicine, the initiative focuses on patients whose needs are often unmet in traditional outpatient settings. These patients frequently experience multiple chronic medical conditions, behavioral health challenges, and unmet social needs such as housing instability and poverty.
Through Bridge to Health, UNC will establish and expand bridging clinics to support patients after hospitalization by addressing acute medical, mental health, and social needs and connecting them to ongoing care and community-based resources. The model is designed to improve patient outcomes and reduce avoidable hospital utilization.
UNC is one of six health systems in North Carolina selected to participate in the initiative. The program includes collaboration with the North Carolina Healthcare Foundation and the Duke-Margolis Institute for Health Policy to support implementation and evaluation.
The work builds on UNC Family Medicine’s longstanding commitment to community-engaged care and improving access for underserved populations. Daaleman is joined by Marni Holder, MSN, RN, director of community health initiatives, and Tim Smith, MPA, who bring extensive experience in community partnerships, program development, and care coordination for vulnerable populations.
The initiative also aligns with UNC Family Medicine’s recent Street Medicine efforts, another program led by Daaleman in collaboration with Holder and Smith. Supported by a federal grant, the Street Medicine program trains residents to provide care for individuals experiencing homelessness in non-traditional settings and to partner with local organizations to support transitions to stable housing and ongoing care.
Both efforts reflect the department’s focus on developing innovative, patient-centered models of care that address the complex factors influencing health and expand access to care across North Carolina.
Read the press release here.