Bridging Health Gaps: Stanford Hospitalists’ Commitment to Community Engagement

August 28, 2025
By John Knox 

Consider two fictitious patients named Ruby and Derrick: Ruby was a familiar patient at Stanford Hospital because of issues related to her diabetes. Derrick also was frequently hospitalized at Stanford for treatment of multiple chronic health conditions.

Ruby’s diabetes issues stemmed from food insecurity. Without reliable access to appropriate food, she struggled to follow dietary recommendations, leading to poor glycemic control and increased risk of complications. For Derrick, housing instability exacerbated his health conditions. For example, after one hospitalization, his discharge instructions were stolen, and his medications were improperly stored without refrigeration.

Food insecurity and housing are among many social drivers of health (SDOHs), the conditions in which people live, learn, work, play, and age. 

Surprisingly, medical care accounts for only about 20% of health outcomes, and up to 80% of the remaining outcomes can be traced to behavioral, socioeconomic, and environmental factors.

In a recent paper, six Department of Medicine faculty (see sidebar) emphasized that “addressing these drivers is crucial for improving health outcomes and advancing health opportunities for all.” 

“The primary takeaway from our early research is the transformative impact of integrating SDOH into hospital medicine through strategic community partnerships. At Stanford Medicine, we have early evidence that addressing drivers — such as housing and food insecurity — can significantly improve patient outcomes and advance health equity,” says Santiago, clinical assistant professor of hospital medicine and lead author of the paper.

Santiago is director of Community Partnership for the Division of Hospital Medicine, a position created in 2024 to address the significant SDOH among patients within the hospital medicine service line. 

The position signifies an expanded commitment in the Department of Medicine to enhance patient outcomes through community engagement and addressing SDOH systematically. 

“Within the department, our primary care division was the first to pilot having an explicit program in community partnership with dedicated leadership. That program, which has now grown into its own section of 15 faculty, was followed by development of a similar section in the hospital medicine division. Other specialist and inpatient divisions within the Department of Medicine can also benefit from integrating SDOH considerations into their practice,” says Jonathan Shaw, MD, inaugural associate chair of community partnership for the Department of Medicine.

The Role of the Hospitalist

In the Division of Hospital Medicine, hospitalists, who often encounter patients at critical junctures in their health journeys,  are uniquely positioned to lead these efforts. 

“Hospitalists have a unique vantage point to observe the interplay between medical conditions and social factors during acute care,” Santiago says. “This allows them to identify and address SDOH proactively, coordinating with community resources to ensure comprehensive care that extends beyond hospital discharge. By leveraging their position, hospitalists can play a crucial role in identifying social needs early and facilitating timely interventions, thus improving health outcomes and reducing disparities.

“Additionally, hospitalists often serve as the primary point of contact for patients during hospital stays, providing them with valuable insights into the social factors impacting health. This perspective enables hospitalists to address SDOH in a meaningful way, collaborating with community partners to provide holistic care that meets the needs of patients,” she adds.

Partnering with Community Resources

Fostering community-academic partnerships is another important job for the hospitalist because it can help bridge the gap between medical care and the social factors that influence health.

By engaging with community organizations, we aim to create sustainable health initiatives that are culturally appropriate and tailored to the specific needs of our local population, ultimately reducing health disparities and improving overall community health,” Santiago says.

In the case of an actual patient like Ruby with diabetes, a partnership between Stanford and Mom’s Meals ensured that the patient received medically tailored, diabetes-friendly meals post-discharge. The meals provided the necessary nutritional support to help manage the patient’s condition effectively, which improved medication adherence and the patient’s overall health. 

“We are currently studying this intervention to assess changes in hospital readmissions and diabetes outcomes. By identifying and responding to these social needs, we believe we can significantly improve health outcomes and patient satisfaction,” says Santiago.

For unhoused patients like Derrick, hospitalists partner with Stanford’s social work department, the Stanford HEARs program, and Santa Clara County to use the Vulnerability Index-Service Prioritization Decision Assistance Tool. The tool helps prioritize individuals for permanent supportive housing. 

“By stabilizing patients’ living situations, we can improve their ability to manage their health conditions and reduce hospital visits,” Santiago says.