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Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health (2019)

Chapter: 6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions

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Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

6

Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions

The committee reviewed a range of approaches that health care sector stakeholders have used to improve social care in health care delivery settings. These approaches are likely to face implementation barriers. Therefore, this chapter discusses the implementation challenges associated with social risk documentation and interventions specific to health care delivery settings (awareness, adjustment, and assistance strategies). Though the committee recognizes the gaps in efficacy and effectiveness evidence about such strategies, it also recognizes that social care integration’s impact—and the ability to test its impact—will be closely linked to the effectiveness of its implementation. The committee, therefore, drew on the peer-reviewed and gray literature and on expert testimony to identify potential challenges to health care delivery-based activities to identify and intervene on social risk factors.

This chapter’s focus is on implementation barriers associated with awareness, adjustment, and assistance activities that can support social care integration. The committee does not address challenges to implementing alignment or advocacy approaches, but instead focuses this chapter on the challenges likely to be faced in implementing within-clinic activities, as these usually must be accomplished before alignment or advocacy can be undertaken. Challenges in alignment or advocacy approaches are also likely.

This overview is not intended to discourage health care systems from implementing social care programs, but rather to facilitate such integration by describing potential implementation pitfalls and highlighting strategies that have been used in some settings to avoid or overcome

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

them. Tables throughout this chapter offer potential strategies to address these key implementation challenges. These strategies are described in greater detail in the section on Implementation Strategies to Overcome Challenges. Examples of health care providers seeking to overcome implementation barriers associated with social care integration can be found in many of the references cited here, including Adams et al. (2017), Burkhardt et al. (2012), Gold et al. (2018), Hamilton et al. (2013), Joshi et al. (2018), Knowles et al. (2018), and LaForge et al. (2018).

CHALLENGES TO INITIATING SOCIAL CARE INTEGRATION

Before social care can be integrated into health care settings, the challenges to initiating such integration must be addressed. These challenges may include, for example, obtaining leadership support and staff buy-in, including new voices from those with expertise in social care alongside traditional health care professionals, and resolving logistical and operational issues.

Health system leadership must buy in to social care integration and be willing to both innovate and prioritize social care integration (Boyce, 2014; Institute for Alternative Futures, 2012). Leadership support may be affected by a number of factors, including system-level challenges, such as limited resources in the face of rising costs of delivering care, regulatory and reporting requirements, and the need to adapt operations and provide ongoing training.

Providers and staff may be concerned that social care integration will involve additional tasks that will compete with limited resources (LaForge et al., 2018; Tong et al., 2018). As evidence to support the integration of social care into health care is nascent, providers may believe that integrating social care into health care may not be impactful enough to justify investing in such integration or may be hesitant to take on unproven approaches.

Support for initiating social care integration may be affected by the organizational culture among staff and leadership as it relates to social care in health care. Some staff may not consider addressing social needs to be part of their job or may think that social needs cannot be addressed from health care settings or may doubt that addressing these needs helps patients (Andermann, 2018; Tong et al., 2018).

Logistical challenges can also take substantial resources and time to address (Institute for Alternative Futures, 2012). Some of these challenges include

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
  • Goal setting. Clinics must first establish goals for social care integration—for example, which patients to screen and how screening data will be used—with little empirical guidance. Goals should account for staff capacity, patient population characteristics, the availability of community resources, existing clinic resources and partnerships, known areas of community need, and current screening practices.
  • Strategy and structure. A coordinated strategy for social care integration may involve planning for project management, staff engagement, testing and iterating integration, workflows, designating staff to oversee integration, communication, and working with external partners (Institute for Alternative Futures, 2012; Pescheny et al., 2018; Thomas-Henkel and Schulman, 2017).
  • Infrastructure. Social care integration requires having enough clinic staff to conduct related tasks. If the integration will involve referrals to social service agencies, community partnerships for such referrals may need to be established, along with a maintenance plan (Boyce et al., 2014) and an evaluation plan. If electronic documentation of social risks is desired, the technology (e.g., the ability to document social needs) to support the effort must be put in place, and staff who will use this technology must be trained and given access to it. Payment structures must be identified, especially in under-resourced care settings, with a maintenance plan (Byhoff et al., 2017; Gunderson et al., 2018; Institute for Alternative Futures, 2012). Value propositions (such as improving quality measures or reducing total cost of care) also must be identified.

Workflow, staffing, and technological challenges—and the methods for addressing them—are discussed in greater detail later in this chapter. Table 6-1 provides a summary of common implementation barriers and potential strategies for initiating social care integration. Establishing payments for social care integration is covered in Chapter 5.

CHALLENGES TO DOCUMENTING AND RESPONDING TO SOCIAL NEEDS

Various potential challenges to documenting and responding to social needs are described here. Identifying social needs is a critical first step to the integration of these needs into health care. Some organizations may want to begin by simply documenting social needs; others will also want to develop systems to respond to these needs. The challenges to documenting and responding to these needs may differ across organizations

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

TABLE 6-1
Potential Strategies for Initiating Social Care Integration

Phase Potential Challenges Strategies to Address These Challenges
Initiating Social Care Integration Leadership support Obtain formal commitment from leaders
Provider and staff buy-in Identify and prepare champions
Organizational culture Engage staff in planning
Logistics Develop clear protocols
Goals Assess local needs and resources, identify barriers
Strategy Develop a formal implementation plan
Structure Revise professional roles and workflows
Infrastructure Adapt payments structures, technology, staffing, or partnerships

and health care settings. See Table 6-2 for a summary of challenges to documenting and identifying social needs and potential strategies to address these challenges.

Challenges to Documenting Social Needs

Logistical

The challenges to identifying and documenting patients’ social needs may include identifying a target population, selecting screening tools, designing workflows, creating staffing plans, providing appropriate training, obtaining the needed technological tools, and making rollout plans. The questions that need to be answered include

  • Which patients? Practices must decide which patients and which needs to screen for or how often screening should occur with little guidance or evidence (O’Gurek and Henke, 2018).
  • Which screening tool or tools? Numerous social needs screening tools exist, but none has been validated to predict specific outcomes, and no standardization exists (O’Gurek and Henke, 2018). Practices must select a tool without guidance. No one tool will meet all of their needs (LaForge et al., 2018). Practices may want to screen for specific social needs if they have partnerships with certain local agencies or avoid others if they lack such partnerships. There is little guidance to suggest how to adapt existing
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

TABLE 6-2
Potential Strategies for Documenting and Identifying Social Needs

Phase Potential Challenges Strategies to Address These Challenges
Documenting Social Needs Logistics Which patients Learn from early adopters, assess local needs and resources, obtain and use patient feedback, use an implementation advisor
Which tool Assess local needs and resources, obtain and use patient feedback
Which workflow Revise professional roles and workflows, conduct small tests of change
When Revise professional roles and workflows, purposely reexamine the implementation
How to administer Revise professional roles and workflows, use an implementation advisor
Who will administer Revise professional roles and workflows, create new clinical teams
Planning for roll out Conduct small tests of change, purposely reexamine the implementation
Staffing Revise professional roles, conduct ongoing training
Use of technology Promote adaptability, use quality monitoring
Identifying Social Needs Provider and staff Perceived lack of resources Alter incentives
Do not see the need Share data with clinicians
May not feel comfortable Engage patients to increase demand
Overburdened Revise professional roles and workflows, create new clinical teams
May not want to change Identify and prepare clinical champions
Patient Not receptive Involve patients in planning
Unprepared on embarrassed Prepare patients to be active participants
Unmotivated to take action Explore patient barriers to action, prepare patients to be active participants
Screening type Obtain and use patient feedback
Clinical relationship Develop patient-centered language to discuss screening efforts
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
  • tools to meet local needs, as is often desired; furthermore, such adaptation can create barriers to scale-up, as discussed below (Gold et al., 2017; LaForge et al., 2018). Practices choosing a screening tool might consider how the collected data will be used, which social needs can be addressed with local resources, which screening tool fits the clinic’s workflows, and the needed granularity of social needs data (e.g., specific financial needs rather than general financial strain) (Gold et al., 2017, 2018; Jensen et al., 2015; Thomas-Henkel and Schulman, 2017).

  • Which workflows? Practices must identify effective social needs screening workflows; ideally, these will integrate into existing workflows (Jensen et al., 2015; Joshi et al., 2018; Stehlik et al., 2017). When identifying workflows, consideration should be given to when the data will be used and to making sure that the data are entered in time. Overall, successful data collection may involve flexibility in where, how, and by whom data are collected. The optimization of these workflows also involves having adequate staff and time and the appropriate technological resources for the data collection.
  • How to staff for social needs screening? Social care integration may involve hiring new staff, removing staff from other activities, or adding to existing workloads. Screening conducted by non-clinical staff (e.g., community health workers) may avoid burdening the clinical staff, but such staff must still be hired, paid, trained,
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

Provider and Staff Challenges to Identifying Social Needs

When implementing social needs screening, the challenges from staff may include discomfort with such screening in general or when no referral is feasible, doubt about why such screening is needed, a lack of time to conduct screening, a lack of training, and difficulty in overcoming previous habits.

Some staff may not think social needs screening is needed or useful (Colvin et al., 2016; Tong et al., 2018) or that it should be addressed by

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

health care staff (Adams et al., 2017; Andermann, 2018; Gold et al., 2017; Nelson et al., 2015; Palacio et al., 2018; Thomas et al., 2018; Tong et al., 2018). Some may think that they know the patient’s situation, question the need for standardized screening, prefer an individualized approach, feel that there is inadequate evidence of the impact of managing social care to justify the effort involved in such integration, or think that patients will not seek out social care resources even if referred (Nelson et al., 2015; Pescheny et al., 2018; Thomas et al., 2018). Some may struggle to change practice habits to include social needs screening (Andermann, 2018; Pescheny et al., 2018), and some may not screen universally, sometimes acting on biases and assumptions about whether a given patient should be screened. Some may lack the EHR expertise needed for screening documentation or find the EHR documentation tools difficult to use or inaccessible to certain staff (Gold et al., 2017). Some may feel too overworked to add social needs screening to their workload, and they may not want to add time to the visit, especially if social needs screening seems incongruous with the visit’s primary purpose (Andermann, 2018; Joshi et al., 2018; Knowles et al., 2018; Palacio et al., 2018; Ridgeway et al., 2013; Thomas et al., 2018; Tong et al., 2018).

Staff may not want to screen for social needs if there are not resources to which they can refer patients to address those needs (Andermann, 2018; Olayiwola et al., 2018; Palacio et al., 2018; Pescheny et al., 2018; Purnell et al., 2018); this situation can cause burnout (Olayiwola et al., 2018; Tong et al., 2018). Staff may feel uncomfortable asking about social needs, overwhelmed by the need they encounter (Andermann, 2018), or apprehensive about their ability to address needs (Palacio et al., 2018; Pescheny et al., 2018; Purnell et al., 2018; Ridgeway et al., 2013). In addition, staff may not want to offend or disturb patients by asking about social needs (Beck et al., 2012; Gold et al., 2017; Hewner et al., 2017; Meredith et al., 2017; Saberi et al., 2017; Thomas-Henkel and Schulman, 2017) or make patients feel stigmatized (although anecdotal evidence suggests that this concern is often unwarranted) (Adams et al., 2017; Knowles et al., 2018). Finally, some staff may experience social needs themselves.1

Patient Challenges to Identifying Their Own Social Needs

Patients may or may not be receptive to social needs screening (Adams et al., 2017; Garg et al., 2007; Jaganath et al., 2018; Katz et al., 2008; Pinto et al., 2016; Quinn et al., 2018; Saxe-Custack et al., 2018). They may feel unprepared to discuss their needs (Katz et al., 2008), embarrassed to discuss their finances (Nguyen et al., 2018; Thomas et al., 2018), unmotivated to

___________________

1 Personal communication, Robyn Gold, Rush University, April 18, 2019.

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

act on their needs, concerned about the legal ramifications of accessing social services (e.g., effect on immigration status), or generally concerned about stigmatization (Pescheny et al., 2018). However, staff should not assume that patients will resist such screening. Patient discomfort may depend on the specific needs (Thomas et al., 2018; Vest et al., 2017) or on their trust of clinic staff (Knowles et al., 2018). Some patients may prefer to disclose sensitive information to providers and staff with whom they share a racial/ethnic, social class, or cultural background, or those who at least demonstrate cultural humility and knowledge of structural determinants of health; this strengthens the argument for a more diverse and culturally competent workforce (Cooper et al., 2003; Murphy et al., 2018).

Challenges to Responding to Social Needs

Some challenges to responding to social needs are similar to those for social needs documentation, but some are unique, such as identifying referral resources, creating and maintaining partnerships with social service providers, and establishing needed data exchanges. Tables 6-3, 6-4, and 6-5 list common challenges to reviewing and responding to social needs and potential strategies to address these challenges.

Challenges to Reviewing Social Risk Data

To successfully integrate social care into health care, processes for reviewing, analyzing, and acting on patient-reported data and communicating results across care team members must be developed and tested

TABLE 6-3
Potential Strategies for Reviewing and Responding to Social Needs

Phase Potential Challenges Strategies to Address These Challenges
Reviewing Social Needs Identify a process Conduct small tests of change, promote adaptability
Identify workflow Engage staff in planning, revise professional role and workflows
Lack incentives Alter incentives, mandate change
Retrieving and reviewing results Conduct small tests of change
Which needs require a response Involve patients in planning, learn from early adopters, assess local needs and resources
Data easy to find and interpret Conduct small tests of change, use data experts
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

TABLE 6-4
Potential Strategies for Internal Referrals

Phase Potential Challenges Strategies to Address These Challenges
Internal Referrals Logistics Staffing and workflow Revise professional roles and workflows, create new clinical teams, ensure adequate staffing
Technology/clear documentation Modify record systems, conduct ongoing training, provide ongoing consultation
Staff Role confusion Revise professional roles, conduct ongoing training
Lack of buy-in/incentives Identify and prepare champions, modify incentives, mandate change
Patient Patients may not accept support Involve patients in planning, address patient provider trust
Patient desire for support not established Involve patients in planning

(Boyce et al., 2014; O’Gurek and Henke, 2018; Pescheny et al., 2018). Effective workflows and staffing for reviewing social needs data must be identified (Andermann, 2018), with little evidence on best practices. If social care referrals are not planned or feasible, the staff may lack incentives to review the documented needs (Gold et al., 2018).

Screening results must be easy to retrieve and review in the EHR (Gold et al., 2018; Jensen et al., 2015; Katz et al., 2008; Vest et al., 2017), but such functionality is not yet in all EHR systems. Care teams must know how to locate these data in the EHR, and the appropriate staff must have access to those data; they also may want guidance on which needs require a response and on the optimal timeframe for that response (Gold et al., 2018; Katz et al., 2008). If staff do not know how to find, interpret, and act on documented social needs data, their review of such data may be limited (Hewner et al., 2017).

Challenges to Responding to Social Needs Data

Broadly speaking, practices may respond to patients’ social needs by adapting care plans to account for these needs or by referring patients “internally” to a clinic social worker or care navigator, to resources provided by the clinic (e.g., food, transportation, or legal services), or externally to local social service agencies. The practice must decide which approach or

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

TABLE 6-5
Potential Strategies for External Referrals

Phase Potential Challenges Strategies to Address These Challenges
External Referrals Logistics Workflow—no appointment made Adapt workflows, conduct small tests of change
Staff roles Clearly define team roles
Knowledge of resources Conduct assessment of local needs and resources
Staff Knowledge of resources Conduct assessment of local needs and resources, develop and distribute educational materials
Patient Already have access Conduct assessment of local needs and resource, involve patients in planning
Negative past experiences Obtain and use patient feedback
Not confident in navigating the system Prepare patients to be active participants, develop and distribute educational materials
Do not believe CBOs can help Obtain and use patient feedback, develop and distribute educational materials
May have already taken action Obtain and use patient feedback
May only be interested in a medical solution Obtain and use patient feedback, develop and distribute educational materials
Fear—stigma, loss of benefit, deportation Involve patients in planning, obtain and use patient feedback
Lack transportation Involve patients in planning, link patients to existing resources, build organizational networks
Lack time Revise workflows, involve patients in planning
Patients lost to follow up Involve patients in planning, prepare patients to be active participants 

NOTE: CBO = community-based organization.

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Phase Potential Challenges Strategies to Address These Challenges
External Referrals Technology Closing the loop Use data experts, change record systems, conduct small tests of change
Data privacy Use data experts, change record systems
Lack of CBO infrastructure Provide local technical assistance, capture and share local knowledge
Other barriers to data exchange Use data experts
Cost for social service lists Refine or innovate billing practices
Clinic staff unaware of technology for referrals Conduct educational meetings, provide ongoing consultation
Staff may not be able to access tools Provide ongoing consultation
May lack mechanism for noting referral in patient record Use data experts, provide ongoing consultation
Partnership Establishing partnerships Build coalitions, establish formal agreements
Barriers to creating and maintaining partnerships Identify and prepare community champions
CBO capacity Adapt payments structures, technology, staffing, or partnerships
Lack of partnership experience Offer training to CBO leadership
Training and implementation support needed Conduct educational meetings, provide ongoing consultation
Effective cross-sector workflow Conduct small tests of change, promote adaptability
Reimbursement challenges Refine or innovate billing practices
CBO financial instability Partner to seek alternative sources of funding
Lack of methods for demonstrating partnership impacts Consult with data and evaluation experts
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

approaches works best for its setting, considering priorities, initiatives, and payment structures; staff resources; available community resources; existing partnerships; and the known areas of need in the community.

Health care organizations may also use social needs data to inform resource allocation, community or policy advocacy, risk stratification, or partnership building. For example, an organization could justify its need for resources to payers and policy makers by presenting collected social needs data. It could also use these data in partnership with insurers to inform the design, implementation, and evaluation of health insurer–directed social service programs, such as medically tailored meal delivery, transportation, and housing. Social needs data could be used to argue for hiring care managers or to offer group visits, special classes, transportation services, income supplements for food or housing, or other services. These data also could be used to help community-based organizations (CBOs) co-develop programs or coordinate referrals. However, staff may not understand these uses of social needs data.

Adapting care plans While some of the ways that care plans might be adapted to address reported social needs are fairly intuitive (e.g., a patient without stable housing should not be prescribed a refrigerated medication), little evidence yet exists to guide such adaptation. Decision support related to social needs might help, but evidence is lacking upon which such decision support could be built.

Internal referrals

  • Logistical challenges. Internal social needs referrals require identifying effective workflows with little guidance, ensuring that staff are available when needed, and obtaining and sustaining funding for this activity (Gunderson et al., 2018). Practices may have limited EHR capacity for supporting internal referrals (Gold et al., 2017, 2018; O’Gurek and Henke, 2018); if the EHR does not support referral documentation, the clinic staff may use less track-able work-arounds such as telephone and faxes (Craig and Calleja Lorenzo, 2014). The staff designated to address social needs may not be experienced in EHR documentation or have EHR access (Craig and Calleja Lorenzo, 2014).
  • Staff challenges. Staff may feel role confusion (Andermann, 2018), turf-related tensions, lack of buy-in, or reluctance to engage in social care management (Jani et al., 2012).
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

External referrals

  • Logistical challenges. If practices wish to refer patients to local social service agencies, one potential challenge is establishing effective workflows. Referrals to CBOs differ from clinical referrals in that they rarely involve making appointments. Few organizations have demonstrated effective processes for CBOs confirming that they served the patient (Lohr et al., 2018). The University of California, Los Angeles, Alzheimer’s and Dementia Care Program established formal partnerships with CBOs that include systemized referrals and electronic communication mechanisms (Tan et al., 2014). If the workflow involves a one-on-one discussion with patients, space and time are needed for such conversations. Practices must determine which staff are best suited to make external social care referrals (Thomas-Henkel and Schulman, 2017); a person in this role will need time to engage with the patient, knowledge of local CBOs, and the ability to use the EHR as needed. Practices must establish and update a list of community service resources, which ideally can be accessed through the EHR (Adams et al., 2017; Andermann, 2018; Gold et al., 2017; LaForge et al., 2018; O’Gurek and Henke, 2018; Thomas-Henkel and Schulman, 2017). Businesses have emerged in recent years to provide and maintain such lists, and these service locators may help practices refer patients to CBOs and communicate and share data with CBOs. Options are discussed in the 2019 Community Resource Referral Platform guide from SIREN, which presents a useful overview (Cartier et al., 2019). Affordability of the service locators can be a challenge.
  • Staff challenges. Practice staff may not understand which individual CBOs are available, what they do and which patients they serve, or how the referral process works (Knowles, 2018).
  • Patient challenges. Not all patients with identified social needs desire clinic intervention to address those needs (Gold et al., 2017, 2018; Pescheny et al., 2018; Tong et al., 2018). They may already access the needed service; be ineligible for certain services; feel discomfort engaging with clinic staff about non-clinical needs; have negative past experiences with such services; lack confidence in navigating such systems on their own; doubt that CBOs can help them; not be ready to take action to address a given need; fear stigmatization, loss to benefits, or deportation; or lack transportation or the time to access such services (Knowles et al., 2018; Pescheny et al., 2018). If the clinic plans to follow up on reported social needs via outreach, patients can be hard to reach (Knowles et al., 2018).
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
  • Technological challenges. Many technological challenges to making and documenting referrals to CBOs exist. EHR functions for listing social service agencies and documenting referrals to such agencies are emerging, but have not been tested. When a patient is referred to a CBO, ideally the medical practice and CBO would be able to communicate about this referral in real time, but challenges to “closing the loop” (i.e., informing the health care entity that the patient accessed the services to which they were referred) remain (Bonney and Chang, 2018; Cartier et al., 2019; Lohr et al., 2018). Sending data through the Web requires practice staff to exit the EHR and re-enter data. Data safety and patient privacy must be addressed, and regional laws and organizational policies may pose challenges (Ridgeway et al., 2013). CBOs may resist responding to practices if different methods are needed for different practices. CBOs may not have the technological infrastructure needed to send information (Amarasingham et al., 2018), nor the staff resources and motivation to respond to the medical practice. The businesses offering tools for data exchange between CBOs and medical settings should address some of these challenges (Amarasingham et al., 2018; Bonney and Chang, 2018; Quinn et al., 2018; Thomas-Henkel and Schulman, 2017) (see Chapter 4 for more details). When social care referrals are documented, clinics may need to document these as distinct from clinical referrals since the rate of closed referrals can be a quality measure.
  • Challenges to creating partnerships with community agencies: health system perspective. Partnerships between CBOs and health care entities are becoming increasingly common. These partnerships address a variety of care coordination and social care needs. Health care–community partnerships, though fundamental for making effective social care referrals, have inherent challenges (Bonney and Chang, 2018; Institute for Alternative Futures, 2012; Pescheny et al., 2018; Thomas-Henkel and Schulman, 2017; Valentijn et al., 2015). The CBO must have the capacity to serve referred clients or the ability to accommodate expanded demand (Garg et al., 2007; Pescheny et al., 2018; Tong et al., 2018). Building partnerships takes time and commitment, and a partnership agreement and governance structure are needed from the start to clarify expectations. Health care systems may cover a large geographic area and therefore need to develop partnerships with multiple local CBOs.
    • CBOs and medical practices may lack experience in cross-service partnership (Jani et al., 2012). Trust is essential, but establishing trust may be challenging due to structural
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
  • Challenges to creating partnerships with community agencies: CBO perspective. CBOs may find clinic partnerships difficult for some of the reasons given above. They may need to establish new organizational relationships, which are possibly made more difficult by power imbalances with better-resourced medical practices. They may lack the staff or staff competencies needed to support such partnerships. They may be unsure whether they will benefit from entering into such partnerships with medical practices directly or through businesses that help coordinate such efforts. For example, CBO-staffed social workers partnering with a clinic to provide biopsychosocial assessment and case management as part of the interprofessional team may offer an effective intervention, but unless the practice refers with enough volume and agrees to share clinical, usage, and cost data with the CBO, it is difficult to develop a business case for the partnership, and
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

funding may not be renewed (American Society on Aging, 2019). Finally, even if they are willing to send data to medical practices regarding services provided to patients, CBOs may not have the technology needed for such data exchange.

Challenges in scaling up social care integration It can be useful to start social care integration in a single practice and then expand; however, future scaling much be considered from the start. Adaptations that facilitate integration in a single setting, such as a local adaptation of screening tools, can lead to future barriers to scaling up. It is highly preferable that the same screening and referral mechanism be used for all systems involved in the scale-up. If CBO referral making is to be expanded, the capacity of CBOs in all affected regions must be considered; a network may need to be created by hiring one of the resource locator businesses that support such development.

IMPLEMENTATION STRATEGIES TO OVERCOME CHALLENGES TO INTEGRATING SOCIAL CARE AND HEALTH CARE

Dissemination and implementation science defines “implementation strategies” as diverse approaches to supporting practice change in some settings and situations (Proctor et al., 2013). Some strategies that might support social care integration are discussed here. Strategies for addressing challenges to social care integration will vary by context. Most of the strategies listed below have effectively supported organizational changes in some practices, but almost none has been assessed specifically for supporting social care integration (Hamilton et al., 2013; O’Gurek and Henke, 2018).

Prepare to Implement Social Care Integration

Whether health care hopes to integrate with social care by documenting a single need or by screening for and acting on many needs, the efforts will be enhanced by communicating a clear and strong commitment from leadership to making this change, creating a formal implementation plan, and putting the needed infrastructure in place before implementation begins. This effort may involve information technology tools for social care documentation and review (Burkhardt et al., 2012; Craig and Calleja Lorenzo, 2014; Gold et al., 2017, 2018; Hewner et al., 2017; Thomas et al., 2018), and some EHR vendors now provide such tools. Medical practices should ensure access to interpreter services or translate the clinic’s social needs screening tool, as appropriate, for the practice’s patient population (Purnell et al., 2018). Practices should also ensure that their staffing is adequate to support intended activities and that funding structures to

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

support integration are in place. The practices will need to decide which patients are targeted for social needs screening, which social needs screening tool will be used, which codes will be used to document social needs, and what actions will be taken to address those needs. Delivery system redesign and practice change efforts should use relationship-centered care principles in setting goals and priorities for social care integration (Beach et al., 2006). As discussed above, preparations for social care integration must consider how such efforts will be scaled up.

Implementation Strategies Targeting Clinical Staff

Many strategies may help address provider and staff integration challenges, including

  • Identify and support a clinical champion to oversee and advocate for social care integration, and give the champion authority and time for implementation activities. Ideally, this person will be trusted by clinical staff and an experienced EHR user (Andermann, 2018; Gold et al., 2018).
  • Engage staff in the planning process (Craig and Calleja Lorenzo, 2014; Gold et al., 2017; Pescheny et al., 2018). Create shared understanding about social care integration to develop buy-in; this may include defining the expectations of clinic staff and community partners.
  • Conduct staff training to cover why the practice is screening for social needs, how the practice will use social needs data to improve patient health, how to conduct and respond to social needs screenings, and how to use EHR tools for social needs screening and referral-making (Andermann, 2018; Burkhardt et al., 2012; Craig and Calleja Lorenzo, 2014; Gold et al., 2018; Pescheny et al., 2018; Stehlik et al., 2017; Thomas-Henkel and Schulman, 2017). Ongoing training may be needed after the social care integration plan is put into place, especially if it is revised or if the information technology tools change, and onboarding staff will need to be trained (Gold et al., 2017). If CBO partners are involved, conduct a joint practice–CBO staff training.
  • Provide clear protocols for social needs screening, including which patients to screen for which social needs at which visits (Andermann, 2018).
  • Provide well-designed workflows for social needs screening, considering data entry methods, a review of social needs data, staff availability and training needs, escalation to other team members (e.g., from community health worker to social worker), and other
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

Implementation Strategies Targeting Patients

Several strategies have been developed to inform patients about social needs screening and its potential benefits and to increase the likelihood that they will be receptive to being screened. These include

  • Explain to the patient why the social needs screening is being conducted—for example, because all new patients are being screened, and it can affect care planning—so as to avoid having the patient feeling singled out or stigmatized (Knowles et al., 2018).
  • Communicate with all patients via a practice newsletter, posters in the waiting room, and patient portals, so patients know what to expect (Pescheny et al., 2018).
  • Use trusted staff to conduct screening. Ensure that the person conducting social needs screening is someone whom patients trust (Thomas et al., 2018).
  • Activate patients to participate in decision making related to their care. Consider helping patients increase their self-efficacy so that they feel able to follow up on referrals to community resources (Andermann, 2018).

Implementation Strategies Targeting Clinic Workflows and Processes

The strategies described below are aimed at improving clinic workflow and processes:

  • Start small, for example, by screening patients seen by one team or provider—or focusing on one screening question—on one day. Small tests of change can accelerate the adoption of social care integration workflows. Test and hone clinic social needs processes on a small scale, address problems, and then scale up. Use quality
Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

Implementation Strategies Targeting Community Partners

Strategies that may help integration challenges experienced by CBOs are listed below.

Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×

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Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health was released in September 2019, before the World Health Organization declared COVID-19 a global pandemic in March 2020. Improving social conditions remains critical to improving health outcomes, and integrating social care into health care delivery is more relevant than ever in the context of the pandemic and increased strains placed on the U.S. health care system. The report and its related products ultimately aim to help improve health and health equity, during COVID-19 and beyond.

The consistent and compelling evidence on how social determinants shape health has led to a growing recognition throughout the health care sector that improving health and health equity is likely to depend – at least in part – on mitigating adverse social determinants. This recognition has been bolstered by a shift in the health care sector towards value-based payment, which incentivizes improved health outcomes for persons and populations rather than service delivery alone. The combined result of these changes has been a growing emphasis on health care systems addressing patients’ social risk factors and social needs with the aim of improving health outcomes. This may involve health care systems linking individual patients with government and community social services, but important questions need to be answered about when and how health care systems should integrate social care into their practices and what kinds of infrastructure are required to facilitate such activities.

Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health examines the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes. This report assesses approaches to social care integration currently being taken by health care providers and systems, and new or emerging approaches and opportunities; current roles in such integration by different disciplines and organizations, and new or emerging roles and types of providers; and current and emerging efforts to design health care systems to improve the nation's health and reduce health inequities.

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