INTRODUCTION

Responding to compelling evidence that links social risks—such as food, housing, transportation, or economic insecurity—to healthcare outcomes, primary care practices are considering how to improve patients’ social conditions (i.e., social care).1,2,3,4,5,6,7,8,9,10 Several forces have spurred the momentum to act on evidence linking social risks and healthcare outcomes including the ongoing shift towards value-based care in the Affordable Care Act and beyond, campaigns advanced by provider organizations such as the American Academy of Family Physicians, and influential reports by the National Academies of Sciences, Engineering, and Medicine and others.11,12 As a result, two-thirds of primary care practices report screening patients for at least one social risk factor (social conditions which are health risks).13 Information on patients’ social risk factors can be used by primary care clinicians to gain a deeper understanding of their patients’ lives, to adjust patient’s care plan (e.g., changes to medications or follow-up schedule), and to improve social conditions.5,6,8,11 For many primary care practices, the next step after social risk screening is likely providing patients with identified social needs (e.g., a social risk factor the patient experiences) with a referral to community-based organizations (CBOs).4,5,11,13,14,15,16,17,18,19,20,21,22,23

Social needs referrals are likely appealing to primary care settings because referrals capitalize on the expertise of CBOs and local resources rather than requiring healthcare organizations to independently develop social needs assistance programs such as housing or job placement support. Thus, primary care practices may use social needs referrals because they are a relatively low intensity social care intervention. Yet, primary care practices likely still face significant challenges providing social needs referrals due to workflow changes, staffing needed, and technology to support implementation.14

Despite evidence that primary care practices are screening patients for social risk factors,6,24 little is known about how they act to resolve patients’ social needs once identified. To address this gap, we interviewed healthcare administrators to explore their motivations, processes, and challenges associated with implementing social needs referrals. These findings can guide primary care practices as they develop and implement social needs referrals. Additionally, insights can inform policymakers and payers as they consider incentivizing social care as part of their effort to improve healthcare outcomes while managing costs.

METHODS

We conducted semi-structured interviews with administrators at healthcare organizations between April 19 and July 26, 2019, to understand how social care activities are implemented in primary care. This study was approved by the Committee on the Protection of Human Subjects at Dartmouth College.

Sample and Outreach

We used three strategies to identify healthcare organizations with current social care activities. First, we randomly sampled systems and primary care practices that reported conducting social risk screening (i.e., food, housing, transportation, utilities, and interpersonal violence) in the National Survey of Healthcare Organizations and Systems (NSHOS).25,26 Fielded from June 2017 to August 2018, NSHOS is a suite of nationally representative surveys that included a system-level survey (N=325, response rate=57%) and a primary care practice-level survey (N=2190; response rate=44%).6,25,26,27,28,29,30 Second, to ensure we sampled organizations that were meaningfully delivering social care, we identified primary care practices and health systems with publicly available information online about social care.

Third, we interviewed organizations participating in the Centers for Medicare and Medicaid Services’ (CMS) Accountable Health Communities (AHC) model.31,32 The AHC model, which began in 2017 (screening began in 2018), tests the impact of social care activities for Medicare and Medicaid beneficiaries within primary care, emergency department, behavioral health, and labor and delivery settings. The AHC model included 2 tracks: alignment and assistance. AHCs are required to screen patients for social risks in clinical settings. If a beneficiary screened positive for social risks, they are given a referral. High-risk beneficiaries were also eligible for assistance accessing resources (in the assistance track, beneficiaries were randomly assigned to receive assistance). Alignment AHCs were required to engaged community resources via an advisory committee.31,32,33,34

At each organization, we emailed an identified leader and asked them to connect us with the individual best suited to discuss their social care activities. Individuals identified by organizational leaders varied in formal titles and roles (Appendix Table 1), but all were responsible for overseeing programming. Interviewees were typically executive leadership (i.e., Chief Executive Officer, Chief Clinical Officer) or program management (i.e., Program Manager, Community Relations) who assumed the day-to-day management of social care activities (Appendix Table 1, Table 4, Table 5).

For the samples identified via NSHOS and Internet searches, we contacted a total of 64 organizations (Appendix Figure 1 details our outreach). Twenty-nine organizations responded and agreed to participate (Appendix Tables 2 and 3 summarize invited organizations). At four organizations, we conducted a second interview to gather additional information about social care activities (Appendix Table 4).

For the AHC sample, we contacted bridge organizations (which are centralized program management offices required in the AHC model) at all AHCs (N=31) participating in the model as of April 2019.32 We interviewed administrators at 22 (of 31) AHCs (Appendix Table 5). At 8 AHCs, we conducted secondary interviews with additional staff members (13 interviews). Two organizations interviewed in the non-AHC sample also participated in the AHC model as clinical sites. We asked these interviewees about activities within and outside of the AHC model and they are counted in both samples, but not twice in the overall number of interviews. The formal evaluation report sponsored by CMS provides detailed information on how AHCs implemented model requirements.31

We conducted outreach in waves to ensure diversity in respondents and continued interviews until we reached a point of saturation.35

Data Collection and Analysis

Trained qualitative interviewers (T.F., a PhD-level health services researcher with advanced training in qualitative research; and L.B., an MPH-level researcher with expertise in healthcare delivery and qualitative methods) conducted the interviews and lead analyses. We followed a semi-structured interview guide that focused on organizational social care efforts including social risk screening, social needs referrals, case management assistance, and partnerships with CBOs (Appendix Table 6). Interviews were conducted via telephone and lasted approximately 1 h. After obtaining consent, interviews were recorded and then professionally transcribed.

We began coding during data collection. First, we coded all transcripts using NVivo.36 The initial coding was broad and used a codebook that was developed prior to coding and aligned with the interview guide domains. The initial coding was conducted by the lead author (L.B.) and a trained research assistant (H.L.). Intercoder reliability was established by having both coders and the senior author (T.F.) iteratively double-code transcripts and discuss discrepancies (Appendix Figure 2).37

We analyzed data on the implementation of social needs referrals in primary care. We conducted intermediate coding where two individuals (L.B. and H.L.) iteratively sub-coded data on social needs referrals that was then reviewed by the senior author (T.F.) with any discrepancies resolved via discussion. To organize and support analyses, we (L.B., H.L., and T.F.) developed an analytic memo that described all observed themes including how each organization fit within each theme. We used a matrix coding approach to justify the inclusion or exclusion of organizations within theme.38

We analyzed transcripts from each sample separately because we expected differences in approaches given the rigorous requirements of the AHC model. Observed themes were consistent across samples. Given this consistency, we report findings pooled across samples. We also examined if approaches varied: (1) by organizational characteristics (e.g., size, ownership, geography) or (2) by the level of the respondent (e.g., administrator in a health system vs. practice) but we did not observe any systematic differences.

RESULTS

We conducted 66 interviews at 50 healthcare organizations. Interviewed organizations included 12 healthcare systems, 1 contracting organization similar to a healthcare system, 9 multi-site multispecialty practices, 6 primary care practices, and 22 AHC bridge organizations (16 alignment and 6 assistance tracks) (Appendix Tables 4 and 5). To protect confidentiality of AHC participants, we are unable to provide detailed information on the organizational characteristics; detail on all AHC model participants can be accessed via CMS’ evaluation year 1 report.31

All interviewed healthcare organizations (N=50) relied on social needs referrals to CBOs as a key component of their effort to improve patients’ social conditions because it allowed them to capitalize on external expertise while limiting the impact of social care efforts on their own organizations.

Then it’s referring people to the food banks because I don’t have capacity to run, nor should I have a food bank in every one of my clinics. That would be redundant for what’s in the community. – Health system

Characteristics of Ideal Social Needs Referral Programs:

Administrators described three characteristics of an ideal referral program. First, social needs referrals should be low intensity and minimize the burden of providing referrals on care teams such that anyone could offer referrals to patients. Second, administrators emphasized that referrals should be tailored to each patient (e.g., referral to a food bank located along the patients’ bus route, that was open when the patient was available, or that offered culturally appropriate food). Third, most administrators wanted closed loop referral systems (bidirectional information sharing with CBOs) to ensure the patient accessed the resource, to determine if the CBO successfully assisted the patient, and to assess the impact of referrals on health care outcomes.

Challenges with Implementing Referrals:

While the implementation processes, such as workforce used to implement social needs referrals, the types of patients who were eligible for referrals, and the degree of integration of referrals within clinical workflows, varied by interviewed organizations, we identified cross-cutting implementation challenges. Administrators reported three main challenges to implementing the ideal social needs referrals: developing and maintaining resource lists, aligning referrals with patients, and measuring the impact of referrals.

Challenge 1: Develop and Maintain Resource Lists

Developing and maintaining referral lists was time-consuming. Most (19 from the non-AHC sample; 9 from the AHC sample) relied on their own staff to identify and document key requirements for each resource, regularly update lists, and integrate feedback from colleagues and patients (Table 1): “We try to update it every six months. We don’t always get around to doing it at six months. Then we try and tell the staff, ‘if you know of any new resources, add it in the database’”- AHC.

Table 1 Developing and Managing Referral Lists Required Substantial Staff Time
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Administrators reported looking for technological solutions that would limit the amount of time their staff spent maintaining resource lists.

Challenge 2: Align Referrals with Individual Patients

Tailored referrals required significant knowledge of the patients’ needs that can be paired with a deep understanding of community resources and, of course, staff available to maintain and apply such knowledge (Table 2).

Table 2 While Tailored Referrals Were the Goal, Generic Referrals Were Less Labor Intensive for Care Teams to Implement
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They have to […]select the resources, so they’re using a little bit of their own knowledge of the patient, what they can glean from the screening tool, what they’ve gotten about the demographic and what they know about the resources. -AHC

Given these pragmatic challenges, most organizations instead provided more generic information to patients based on the type of need (e.g., housing, food) or geographic location (e.g., resources by ZIP Code). This allowed administrators to scale activities because anyone in the clinic could give a patient a pre-printed list of resources without disrupting (or adding to) clinical workflows. When social needs referrals were more generic, it became the patients’ responsibility to identify the CBO that might best fit their needs. Some organizations helped patients select ideal CBOs:

They will specifically say to the patient, ‘Hey, here’s this list on all this food stuff. These three are the ones that are going to address your need and when you go Tonya is the girl that works at the front desk. She always wears a flower behind her ear.’– AHC

These challenges were amplified for AHCs because they were required to screen and refer a high volume of patients which resulted in most AHCs using pre-printed referrals.

Challenge 3: Measure the Impact of Social Needs Referrals

Administrators hoped referrals to CBOs were effective at improving patients’ social conditions, but administrators also expressed uncertainty about the efficacy of referrals. Since patients were neither involved in the development of referrals programs nor formally engaged throughout the process for feedback, administrators were unsure if referrals offered value to patients. For example, administrators were unsure if patients accessed CBOs, if patients had prior knowledge of the resource, or if their needs were fully addressed. Administrators thought that closed-loop referrals, where healthcare organizations can track if patients were able to access a resource and resolve their social needs, were necessary to assess the impact of referral programs. Many relied of care teams to manually “close the loop” as part of their effort to measure the impact of referrals on patient outcomes:

Or they did make the connection, and so then we know the next time we can reassess that and is that still a determinant? Are they still struggling with that, or is that getting better for them? We felt like we can link them with a resource, that if we didn’t add that follow up piece to it, it wasn’t really closing that loop. – Practice

Potential for Referral Platforms to Mitigate Challenges:

Some organizations (6 from the non-AHC sample; 12 from the AHC sample) used or were planning to use referral platforms with the hope that by leveraging technology, their processes would be more efficient with fewer staffing resources needed to manage and track referrals. While referral platforms offered advantages, organizations also faced implementation challenges including (1) buy-in and consistent use by care teams and CBOs; (2) platform and electronic health record (EHR) integration; (3) management and prioritization of resources; and (4) alignment with other organizations in their market (Table 3). Administrators reported that these barriers prevented them from using referral platforms as envisioned. At the time of the interviews, referral platforms alone were not enough to overcome challenges associated with maintaining resource lists, tailoring referrals, and tracking the impact of referrals.

Table 3 Implementing Social Needs Referral Platforms Was More Challenging than Expected
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DISCUSSION

Social needs referrals may be pursued by healthcare organizations because referrals are viewed as the most manageable approach to delivering social care. Regardless of the intensity of their approach to social needs referrals—from generic pre-printed lists to highly personalized lists curated by staff—administrators felt referrals required substantial staffing investments (and, therefore, social care activities were costly).39 Developing, implementing, aligning, and evaluating social needs referrals represented significant challenges for healthcare organizations.

The use of social needs referrals within primary care to improve patients’ social conditions is not surprising as it allows healthcare to capitalize on the expertise and resources of others. Administrators believed that social needs referrals were easier to implement because there was less disruption to clinical workflows than directly assisting patients (i.e., delivering food to patients). Yet, administrators emphasized that social needs referrals were more challenging than expected. Administrators struggled to balance the use of pragmatic generic social needs referrals with the personalized, tailored referrals that they felt were more effective. As policymakers consider incentivizing social needs referrals, further research to determine what makes an effective referral (e.g., degree of tailoring needed) and defining which referral elements are essential will aid implementation.

Administrators expressed noteworthy concerns around the efficacy of social needs referrals.40 There is some evidence that social needs referrals, especially within pediatric settings, can improve care outcomes.23,41,42 Yet, significant gaps in the literature remain. Our study highlights concerns around patients’ baseline knowledge of CBOs (e.g., if referrals offer value), how often patients access resources included in referrals, and if those resources improve social conditions and clinical outcomes in the long-term. Healthcare organizations considering how they can improve patients’ social conditions could benefit from guidance on how to effectively structure and implement social needs referrals, particularly around the inclusion of patients’ perspectives.43 Greater guidance from and engagement with patients will help healthcare organizations better understand the efficacy of social needs referrals.

Technology-based solutions to social needs referrals, such as platforms NowPow or Aunt Bertha, have garnered significant interest and investment across the healthcare sector.39,44,45,46 Interviewees reported high hopes that platforms might ease implementation of social needs referrals, increase value for patients through more tailored referrals, and demonstrate the efficacy of their efforts by tracking CBO resource utilization. At least in the relatively early stages of using referral platforms among interviewees, the reality was not quite as hoped. This finding aligns with challenges reported in other studies, particularly the challenge of recruiting CBOs to actively use the platform.22,39,45,47 Referral platforms alone cannot resolve challenges around the hard work of developing meaningful cross-sector collaboration with CBOs and achieving buy-in across clinical teams.

Ideally, referral platforms can be used as a tool to facilitate community-wide engagement around improving population health. Yet, few of the interviewed healthcare organizations designed social needs referrals programs with the input of either patients or CBOs. Social needs referrals programs were designed to deliver social care while mitigating the impact on clinical care activities. While pragmatic and understandable, this approach, from the beginning, limits engagement of local CBOs whose expertise and buy-in is needed to achieve long-term improvements in community health.48,49 Policymakers considering how to incentivize social care in clinical settings could require more meaningful engagement between healthcare and CBOs such as by requiring cross-sector leadership for social care activities, reimbursement to CBOs for services, or requiring CBOs participate in and receive a portion of shared savings in value-based contracts.

Our study has key limitations. First, our data were largely from the perspective of administrators who were responsible for overseeing social care activities which may not represent the views of clinicians or others within the organization. Qualitative interviews are not meant to be generalized, rather interviews provide context and background on how healthcare organizations provide social needs referrals. Finally, these findings are from organizations that were committed to delivering social care and may not represent the views of organizations not already delivering social care. As a result, the challenges we identified may be even greater for organizations starting to deliver social care.

There is growing interest among healthcare delivery systems, payers, and policymakers on how to leverage the expertise and capacity of local resources to improve patients’ health. Among our interviewees, social needs referrals were viewed as the logical approach to improving patients’ social needs. Yet, there were also concerns as to whether healthcare organizations could deliver social needs referrals which are relevant and valuable to patients while also successfully balancing constraints around staffing and capacity. As heathcare organizations increasingly invest in social care, they could use guidance from policymakers and research on how to effectively structure social needs referrals.