Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Jan-Dec:14:21501319231166918.
doi: 10.1177/21501319231166918.

Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System

Marc Shi  1 , Kevin Fiori  2   3 , Ryung S Kim  2 , Qi Gao  2 , Galina Umanski  2 , Iby Thomas  2 , Andrew Telzak  2 , Earle Chambers  2
Affiliations

Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System

Marc Shi et al. J Prim Care Community Health. 2023 Jan-Dec.

Abstract

Objectives: Identifying social needs is a growing priority in primary care, but there is significant variation in how patients access services to meet such needs. This study identifies predictors of successful linkage with a community health worker (CHW) among patients with social needs seen in an outpatient setting.

Methods: This study uses a cross-sectional analysis of social needs assessments administered in an urban health system between April 2018 and December 2019. Social needs included: food insecurity, housing quality, housing instability, healthcare cost, healthcare related transportation, utilities, care for dependents, legal assistance, safety, and getting along with household members. Patients with at least 1 social need and accepting help were included in the analysis. On contact with a CHW, patients were entered into a separate database. The primary outcome was successful "linkage," defined by having a positive social needs assessment in the medical record and a corresponding record in the CHW database. Multivariate logistic regression was used to assess predictors of linkage.

Results: Among patients with at least 1 social need accepting help, 25% (758/3064) were linked to a CHW. Positive predictors included female gender (OR 1.28 [95% CI 1.01-1.63]), Spanish language preference compared to English (1.51 [1.14-1.03]), and having a food related need (1.35 [1.03-1.79]). Negative predictors included age 18 to 65 (0.34 [0.17-0.71] for age 18-24) and 0 to 5 (0.45 [0.24-0.78]) compared to over 65, non-Hispanic White race compared to Hispanic race (0.39 [0.18-0.84]), and having needs of getting along with household members (0.52 [0.38-0.71]) and safety (0.64 [0.42-0.98]).

Conclusions: Twenty-five percent of patients who had at least 1 social need and were accepting help had a successful CHW linkage. Predictors of linkage suggest areas of further system-level improvements to screening and referral interventions to target at risk patients and communities.

Keywords: community health; primary care; social determinants of health; social needs; underserved communities.

PubMed Disclaimer

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Workflow for screening and referral to resources in the Community Linkage to Care Program. Abbreviation: CHW, Community Health Worker.
Figure 2.
Figure 2.
Cascade from social needs screening to linkage to CHW in the Community Linkage to Care Program. Abbreviation: CHW, Community Health Worker.
See this image and copyright information in PMC

References

    1. Horwitz LI, Chang C, Arcilla HN, Knickman JR.Quantifying health systems’ investment in social determinants of health, by sector, 2017-19. Health Aff. 2020;39(2):192-198. doi: 10.1377/HLTHAFF.2019.01246 - DOI - PubMed
    1. Braveman P, Gottlieb L.The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2:19-31. doi: 10.1177/00333549141291S206 - DOI - PMC - PubMed
    1. Bickerdike L, Booth A, Wilson PM, Farley K, Wright K.Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open. 2017;7(4):e013384. doi: 10.1136/BMJOPEN-2016-013384 - DOI - PMC - PubMed
    1. Onie RD, Lavizzo-Mourey R, Lee TH, Marks JS, Perla RJ.Integrating social needs into health care: a twenty-year case study of adaptation and diffusion. Health Aff. 2018;37(2): 240-247. doi: 10.1377/HLTHAFF.2017.1113 - DOI - PubMed
    1. Sokol R, Austin A, Chandler C, et al. Screening children for social determinants of health: a systematic review. Pediatrics. 2019;144(4):e20191622. doi: 10.1542/peds.2019-1622 - DOI - PMC - PubMed

Publication types