From Policy Statement to Practice: Integrating Social Needs Screeningand Referral Assistance With Community Health Workers in an Urban AcademicHealth Center

摘要

Social and economic factors have been shown to affecthealth outcomes. In particular, social determinants of health (SDH) are linkedto poor health outcomes in children. Research and some professional academiessupport routine social needs screening during primary care visits. Translatingthis recommendation into practice remains challenging due to the resourcesrequired and dearth of evidence-based research to guide health center levelimplementation. We describe our experience implementing a novel social needsscreening program at an academic pediatric clinic. TheCommunity Linkage to Care (CLC) pilot program integrates social needs screeningand referral support using community health workers (CHWs) as part of routineprimary care visits. Our multidisciplinary team performed process mapping,developed workflows, and led ongoing performance improvement activities. Weestablished key elements of the CLC program through an iterative process Weconducted social needs screens at 65% of eligible well-child visits from May2017 to April 2018; 19.7% of screens had one or more positive responses.Childcare (48.8%), housing quality and/or availability (39.9%), and foodinsecurity (22.8%) were the most frequently reported needs. On average, 76% ofproviders had their patients screened on more than half of eligible well-childvisits. Our experience suggests that screening forsocial needs at well-child visits is feasible as part of routine primary care.We attribute progress to leveraging resources, obtaining provider buy-in, anddefining program components to sustain activities.