Memorial Regional Health Tackles Social Needs Through Care Coordination

What happens when you have a chronic condition, but the real problem isn’t medical?

It’s not a broken bone or a bad flu. It’s the fact that you can’t afford the medication because you spent your last hundred dollars on heating bills. It’s the confusion over whether a new symptom means you need to go to the ER, or if you can just wait until your next appointment. It’s the stress of not knowing where your next meal is coming from, which makes your blood pressure spike regardless of what the doctor prescribed.

At Memorial Regional Health, they’ve decided that fixing the body isn’t enough if the life surrounding it is falling apart. That’s why they’re leaning hard into Care Coordination — a service designed to be that extra pair of hands and eyes for patients navigating the messy intersection of health and daily survival.

“The actual term ‘Care Coordination’ originally meant a person who was providing additional support for someone receiving medical care,” said Paula Belcher, MRH’s Population Health Director. “We do that, and we also provide for what might be considered ‘social’ needs, which is more commonly referred to as ‘Community Health Work.’ We use the terms somewhat interchangeably, and we provide both.”

The logic is straightforward. If a patient is stressed about money or food, their health suffers. Period. So, the team at MRH isn’t just waiting for you to show up with a fever. They’re looking at the whole picture.

Take the routine questions that usually clog up a doctor’s schedule. You’re taking a new medication and it’s making you sleepy. Is that normal? You’re doing rehab exercises and your elbow hurts. Should you stop? You’re not sure if your breathing treatment is working.

Instead of you driving to the clinic, or the doctor pausing a surgery to answer a quick query, a care coordinator steps in. They talk to the provider. They figure out the answer. They call you back. It saves time for the provider and time for you.

“This approach saves money for both parties, it saves time, and everybody benefits,” Belcher said.

But the real shift is in the "social" side of things. The team focuses on what experts call "social determinants of health." That’s a fancy way of saying: financial instability, food insecurity, barriers to accessing care, and inadequate safety at home. These aren’t just background noise; they actively make you sicker.

One of the first things the coordinators do is sit down with an individual and help them make a budget. It sounds simple, but for many, it’s a foreign concept.

“One of the first things we’ll do with an individual through this approach is sit down and help them make a budget,” Belcher explained. “A lot of times that’s something they’ve never done, and without it, folks might not have a good understanding of their money-in and money-out, and what they might need to do once they visually see, ‘Okay, this is what I have to do to break even,’ or even to get ahead.”

When you understand your finances, you reduce the stress that exacerbates your health conditions. When you know where your next meal is coming from, your body can focus on healing. It’s a cycle of support that starts with a conversation, not a prescription.

The goal isn’t to replace the doctor. It’s to make sure the patient has the stability to actually follow the doctor’s advice. As Belcher puts it, it’s about finding “someone to walk with you” through the challenges that don’t fit neatly into a medical chart.

And that’s the promise of this model: it’s not just about treating the illness. It’s about stabilizing the life around it.