How to Scale the Integration of Social Care Into Health Care: Ideas for Research and Practice Free

Over the past decade, the health care sector has given growing attention to the social risk factors that affect patients’ health. The COVID-19 pandemic brought even more consideration to these influences because we witnessed an exacerbation of existing socioeconomic disparities and their effects on morbidity and mortality. As such, screening patients or their families for social risk factors, including but not limited to food insecurity, housing instability, and unreliable transportation, and providing referrals to community resources is becoming common practice in health care settings across the United States.¹  Yet, little research has evaluated the potential effect of these systems external to highly controlled trials. In this issue of Pediatrics, Garg and colleagues add important discoveries and present new findings on the implementation of a clinic-based social needs screening and referral system in community health centers (CHCs) and its associations with child health.² 

In their type 1 hybrid effectiveness-implementation trial, Garg and colleagues’ implementation of the WE CARE social care system resulted in more families being referred for unmet needs and better adherence to immunizations, but its overall effect on health care utilization and maltreatment in early childhood was mixed.²  We view their study as providing essential insights that will inform future research and practice regarding how to adapt and iterate social needs screening and referral systems for continuous improvement and eventual success in real-world settings.

As described by the authors, the low implementation of WE CARE in the CHCs may have driven mixed findings.²  This version of the WE CARE model included features that facilitated potential intervention reach while reducing CHC burden, including integrating screening into patients’ electronic health records, generating automated referral resources, and requiring little additional workforce and training (ie, 3.5 hours of training existing clinical staff, 1 patient navigator for 3 CHCs). Yet, WE CARE implementation remained low even with these scalability features,²  suggesting that health centers require substantially more support to effectively deploy social care systems. This support may begin with employing interprofessional teams that include experts in social care, such as social workers and community health workers, with sufficient time to meet with families and connect them to resources.³  Moving upstream, integrating social care experts into health care delivery likely requires interprofessional education spanning foundational education through continuing professional development that provides a shared understanding regarding how to effectively and equitably integrate different professions to center patient wellbeing.

The potential benefits of light-touch social care systems designed for wide population reach, such as the WE CARE model, may be limited to patients and their families who (1) have the time and existing social capital to act on referrals and receive services, (2) live in communities with readily available, accessible, and high-quality resources, and (3) are in a position in which they can trust resources external to their immediate support structures. Future research should test this hypothesis and identify opportunities to increase the equity of social care integration systems, which may include methods beyond screening/referral models, such as adjustment (ie, altering clinical care to accommodate identified social barriers), alignment (ie, investing in and deploying existing social care assets in the community), and advocacy (ie, working with partner organizations to promote policies that facilitate equitable population health).³ 

Across various social care models, including Garg and colleagues’ presently evaluated WE CARE model, researchers have found these systems result in more referrals to community resources.^2,4–8  Although the number of resource referrals provided is a valuable process indicator, referrals alone do not equate to improved child health and wellbeing. The path from community referrals to improved child health is complex and involves several intermediary steps, including families following up with referrals, connecting with agencies, and ultimately receiving services or resources. Such intermediary steps likely depend on several facilitators and barriers, including the referred agencies’ capacities and qualities, families’ time to invest in connecting to resources, and support in navigating social care systems.⁹  The field needs more information regarding what happens post-referral: who connects to community agencies and receives services, and what are their interactions with and attitudes toward services; who connects to agencies but does not receive services, and what prevents them from receiving services; who does not connect to agencies post-referral, and why does this hand-off not happen? Future qualitative work with families and community-based providers could investigate these intermediate steps and provide important insights into families’ experiences with and attitudes toward social care systems.

Overall, we recommend future researchers build on Garg and colleagues’²  findings to effectively integrate social care into health care. By identifying who is supported and overlooked by existing models and understanding the intermediary steps between referrals and health outcomes, we can have a better idea of how these systems are working in practice with the goal of iterating them to equitably improve population health.

CHC

community health center