From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center

Abstract

Purpose: Social and economic factors have been shown to affect health outcomes. In particular, social determinants of health (SDH) are linked to poor health outcomes in children. Research and some professional academies support routine social needs screening during primary care visits. Translating this recommendation into practice remains challenging due to the resources required and dearth of evidence-based research to guide health center level implementation. We describe our experience implementing a novel social needs screening program at an academic pediatric clinic. Methods: The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using community health workers (CHWs) as part of routine primary care visits. Our multidisciplinary team performed process mapping, developed workflows, and led ongoing performance improvement activities. We established key elements of the CLC program through an iterative process We conducted social needs screens at 65% of eligible well-child visits from May 2017 to April 2018; 19.7% of screens had one or more positive responses. Childcare (48.8%), housing quality and/or availability (39.9%), and food insecurity (22.8%) were the most frequently reported needs. On average, 76% of providers had their patients screened on more than half of eligible well-child visits. Discussion: Our experience suggests that screening for social needs at well-child visits is feasible as part of routine primary care. We attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.

Keywords: community health workers; implementation; improvement; pediatrics; quality; social determinants of health.

Figure 1.

Schematic of Community Linkage to Care program elements.

Figure 2.

Community Linkage to Care health center workflow for social needs screening and community health worker referrals.

Figure 3.

Summary of monthly social determinant of health screens (bar) and social needs screening percentages (line) with key time events from May 1, 2017 to April 1, 2018. Key time events from project log (with Community Linkage to Care [CLC] program component in boldface): A1: Four residents and a chief resident depart and 4 interns begin (Social Needs Screening and Referrals). A2: Two attending physicians depart, including a project leader, and 2 new clinicians begin (Provider Champion, Social Needs Screening and Referrals). A3: Nursing provider champion departs (Provider Champion). A4: Nursing staff shortage due to multiple vacancies (Social Needs Screening). A5: One of 2 community health workers (CHWs) takes extended leave (Referrals and Accompaniment). A6: New administrative liaison, reinvigorated patient-centered medical home (PCMH) meetings, use of huddles by provider champion to discuss workflow (Administrative Liaison, Provider Champion and Social Needs Screening.

Figure 4.

Summary of monthly number of “active” providers^a (bar) and percentage of “active” providers (line) from May 1, 2017 to April 1, 2018. ^a “Active” provider defined as provider using social needs screen at >50% of eligible well-child visits for that month.