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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.
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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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Page 138
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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Page 139
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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Page 140
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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Page 141
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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Page 142
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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Page 143
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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Page 144
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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Page 145
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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Page 146
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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Page 147
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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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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Page 156
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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Page 157
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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Page 158
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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Page 159
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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Page 160
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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Page 161
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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6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions T he committee reviewed a range of approaches that health care sec- tor stakeholders have used to improve social care in health care delivery settings. These approaches are likely to face implemen- tation barriers. Therefore, this chapter discusses the implementation challenges associated with social risk documentation and interventions specific to health care delivery settings (awareness, adjustment, and as- sistance 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 focused 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 integra- tion by describing potential implementation pitfalls and highlighting strategies that have been used in some settings to avoid or overcome 137 PREPUBLICATION COPY—Uncorrected Proofs

138 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE them. Tables throughout that 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 im- plementation barriers associated with social care integration can be found in many of the references cited here, including Adams et al. (2017), Bur- khardt 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 chal- lenges 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 opera- tional 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, regula- tory 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 inte- gration 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 un- proven 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 (IAF, 2012). Some of these challenges include • Goal setting. Clinics must first establish goals for social care inte- gration—for example, which patients to screen and how screening PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 139 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 in- tegration may involve planning for project management, staff engagement, testing and iterating integration, workflows, desig- nating staff to oversee integration, communication, and working with external partners (IAF, 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 in- volve referrals to social service agencies, community partner- ships 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 technol- ogy (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; IAF, 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 pay- ments 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 organiza- tions 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. PREPUBLICATION COPY—Uncorrected Proofs

140 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE TABLE 6-1  Potential Strategies for Initiating Social Care Integration Phase Potential Challenges Strategies to Address These Challenges Leadership support Obtain formal commitment from leaders Initiating Social Care Integration Provider and staff buy-in Identify and prepare champions Organizational culture Engage staff in planning Logistics Develop clear protocols Assess local needs and resources, identify Goals barriers Strategy Develop a formal implementation plan Structure Revise professional roles and workflows Adapt payments structures, technology, Infrastructure staffing, or partnerships 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 train- ing, 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 have been validated to predict specific out- comes, and no standardization exists (O’Gurek and Henke, 2018). Practices must select a tool without guidance. No one tool may 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 partner- ships. There is little guidance to suggest how to adapt exist- ing tools to meet local needs, as is often desired; furthermore, such adaptation can create barriers to scale-up, as discussed be- low (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 granu- larity of social needs data (e.g., specific financial needs rather than PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 141 TABLE 6-2  Potential Strategies for Documenting Social Needs Phase Potential Challenges Strategies to Address These Challenges 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 Documenting Social Needs 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 Provider Perceived lack of Alter incentives and staff resources Do not see the need Share data with clinicians May not feel Engage patients to increase demand comfortable Identifying Social Needs Overburdened Revise professional roles and workflows, create new clinical teams May not want to Identify and prepare clinical change champions Patient Not receptive Involve patients in planning Unprepared on Prepare patients to be active embarrassed participants Unmotivated to take Explore patient barriers to action, action prepare patients to be active participants Screening type Obtain and use patient feedback Clinical relationship Develop patient-centered language to discuss screening efforts PREPUBLICATION COPY—Uncorrected Proofs

142 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE 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 ad- equate staff and time and the appropriate technological resources for the data collection. o When will social needs screening occur? Timing challenges in- clude the difficulty and time-consuming nature of reaching some patients, ensuring accessibility of social needs infor- mation during practice visits, patients’ ability to complete the screening quickly, and patient ability to enter data using tools such as Web portals (Jensen et al., 2015; Katz et al., 2008; Thomas et al., 2018). o How will social needs screening be administered? There is little evidence to indicate which data collection mode patients pre- fer (Gottlieb et al., 2015; LaForge et al., 2018). Paper forms may be difficult for some patients to complete (Beck et al., 2012; Craig and Calleja Lorenzo, 2014; Thomas et al., 2018). Staff-led screenings and real-time data entry may delay workflows (Gold et al., 2017, 2018). Using tablets and kiosks requires creating and maintaining electronic health record (EHR) connections and tracking and sterilizing the devices; technological glitches can prevent data capture (Jensen et al., 2015), and some clinics and staff may not have access to these technologies (Craig and Calleja Lorenzo, 2014). • 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 (for example, community health workers) may avoid burdening the clinical staff, but such staff must still be hired, paid, trained, given EHR access, and supervised; furthermore, these professions have high burnout rates (Bonney and Chang, 2018; Gunderson et al., 2018; Joshi et al., 2018; Pescheny et al., 2018; Rogers et al., 2018). Staff with time to conduct social needs screen- ing may not be those best suited for the task (Thomas-Henkel and Schulman, 2017). Volunteers may be able to conduct social needs screening, but they may not be able to maintain regular PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 143 schedules, turnover may necessitate finding and training replace- ments, volunteers may need access to data entry tools to ensure consistent record keeping, and patients may be uncomfortable with volunteers (Pescheny et al., 2018). • How and when to provide training? Training staff to conduct social needs screening requires conducting a needs assessment of the targeted learners, developing or identifying an appropriate cur- riculum, identifying appropriate educational methodologies, se- lecting and training the trainers, creating an evaluation plan, and allocating funding, time, and space for the training to occur. • Do the available technological tools support social needs screening? Practices using paper-based screening for social risk factors will struggle to track social needs or related referrals. EHR docu- mentation, though preferable, can pose its own challenges (Joshi et al., 2018). These include having the ability to set up or adapt EHR-based social needs documentation (Gold et al., 2017; Stehlik et al., 2017), ensuring that the EHR supports standardized, user- friendly documentation (Adams et al., 2017; Hripcsak et al., 2015; Pinto et al., 2016; Stehlik et al., 2017) and data exchange with clinical partners (Hripcsak et al., 2015; Jensen et al., 2015; Joshi et al., 2018; Stehlik et al., 2017), and coding for social needs and referrals without national standards for doing so (Adams et al., 2017; Gottlieb et al., 2014; Hewner et al., 2017; Lewis et al., 2016; Monsen et al., 2018). • How to “roll out” social needs screening? The implementation of social needs workflows may falter if the change is applied to an entire organization all at once. 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 refer- ral 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 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 PREPUBLICATION COPY—Uncorrected Proofs

144 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE 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; Pe- scheny 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 docu- mentation or find the EHR documentation tools difficult to use or inacces- sible 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 incongru- ous 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, over- whelmed by the need they encounter (Andermann, 2018), or apprehen- sive 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 (Ad- ams 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), unmo- tivated to 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 dis- comfort 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 1 Personal communication, Robyn Gold, Rush University, April 18, 2019. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 145 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 re- ferral 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 commu- nicating results across care team members must be developed and tested (Boyce et al., 2014; O’Gurek and Henke, 2018; Pescheny et al., 2018). Ef- fective 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 incen- tives to review the documented needs (Gold et al., 2018). TABLE 6-3  Potential Strategies for Reviewing and Responding to Social Needs Phase Potential Challenges Strategies to Address These Challenges Identify a process Conduct small tests of change, promote adaptability Reviewing Social Needs 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 PREPUBLICATION COPY—Uncorrected Proofs

146 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE TABLE 6-4  Potential Strategies for Internal Referrals Phase Potential Challenges Strategies to Address These Challenges Logistics Staffing and Revise professional roles and workflow workflows, create new clinical teams, ensure adequate staffing   Technology/clear Modify record systems, conduct documentation ongoing training, provide ongoing consultation Internal Referrals Staff Role confusion Revise professional roles, conduct ongoing training   Lack of buy-in/ Identify and prepare champions, incentives modify incentives, mandate change Patient Patients may not Involve patients in planning, address accept support patient provider trust   Patient desire Involve patients in planning for support not established 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 “in- ternally” 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 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 PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 147 TABLE 6-5  Potential Strategies for External Referrals Strategies to Address These Phase Potential Challenges Challenges Logistics Workflow—no Adapt workflows, conduct small appointment made 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 Obtain and use patient feedback experiences Not confident in Prepare patients to be active External Referrals navigating the system participants, develop and distribute educational materials Do not believe CBOs can Obtain and use patient feedback, help develop and distribute educational materials May have already taken Obtain and use patient feedback action May only be interested in Obtain and use patient feedback, a medical solution develop and distribute educational materials Fear—stigma, loss of Involve patients in planning, obtain benefit, deportation 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 continued PREPUBLICATION COPY—Uncorrected Proofs

148 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE TABLE 6-5  Continued Strategies to Address These Phase Potential Challenges Challenges 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 Provide local technical assistance, infrastructure capture and share local knowledge Other barriers to data Use data experts exchange Cost for social service Refine or innovate billing practices lists Clinic staff unaware of Conduct educational meetings, technology for referrals provide ongoing consultation Staff may not be able to Provide ongoing consultation access tools May lack mechanism for Use data experts, provide ongoing External Referrals noting referral in patient consultation record Partnership Establishing partnerships Build coalitions, establish formal agreements Barriers to creating and Identify and prepare community maintaining partnerships champions CBO capacity Adapt payments structures, technology, staffing, or partnerships Lack of partnership Offer training to CBO leadership experience Training and Conduct educational meetings, implementation support provide ongoing consultation needed Effective cross-sector Conduct small tests of change, workflow promote adaptability Reimbursement Refine or innovate billing practices challenges CBO financial instability Partner to seek alternative sources of funding Lack of methods Consult with data and evaluation for demonstrating experts partnership impacts PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 149 partnership building. For example, an organization could justify its need for resources to payers and policy makers by presenting collected social needs data. They could also use these data in partnership with insurers to inform the design, implementation, and evaluation of health insurer–di- rected 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, transporta- tion 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 medica- tion), 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 iden- tifying 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). External referrals • Logistical challenges. If practices wish to refer patients to local social service agencies, one potential challenge is establishing ef- fective workflows. Referrals to CBOs differ from clinical referrals in that they rarely involve making appointments. Few organiza- tions have demonstrated effective processes for CBOs confirming PREPUBLICATION COPY—Uncorrected Proofs

150 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE that they served the patient (Lohr et al., 2018). The University of California, Los Angeles, Alzheimer’s and Dementia Care Pro- gram 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 discus- sion with patients, space and time are needed for such conver- sations. Practices must determine which staff are best suited to make external social care referrals (Thomas-Henkel and Schul- man, 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 com- munity 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 indi- vidual 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 confi- dence 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). • Technological challenges. Many technological challenges to mak- ing 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 pa- tient is referred to a CBO, ideally the medical practice and CBO would be able to communicate about this referral in real time, but PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 151 challenges to “closing the loop” (i.e., informing the health care entity that the patient accessed the services to which they were re- ferred) 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 differ- ent 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 fundamen- tal for making effective social care referrals, have inherent chal- lenges (Bonney and Chang, 2018; IAF, 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. o 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 in- equalities. Practices may not understand how their partner- ship affects the CBO or the CBO’s ability to engage as desired. Both parties may need training and implementation support to adopt this change (Amarasingham et al., 2018; Kunkel et al., 2018; Thomas-Henkel and Schulman, 2017). Effective cross-sector workflows are hard to establish (Amarasingham et al., 2018). PREPUBLICATION COPY—Uncorrected Proofs

152 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE o CBOs’ financing and technological systems differ from those of medical practices. Equitable reimbursement models may be difficult to establish (Amarasingham et al., 2018; Bonney and Chang, 2018; Griffin et al., 2018; Gunderson et al., 2018; Thomas-Henkel and Schulman, 2017), which may be exac- erbated by local policies on reimbursement. CBOs funded by short-term grants may struggle to sustain partnerships (Amarasingham et al., 2018; Gunderson et al., 2018; Pescheny et al., 2018). Related payment challenges and strategies are discussed in Chapter 5. o There also are challenges to studying the impact of medical– CBO partnerships, including that it may not be feasible to share or analyze the needed data, effects on health outcomes may not manifest quickly, and CBOs may not maintain records that enable identifying clients referred from a given clinic. These factors can make it hard to sustain such partnerships (Amarasingham et al., 2018; IAF, 2012). It should be noted that the privacy protections contained in the Health Insurance Portability and Accountability Act of 1996 may allow for sharing of patient data between medical practices and CBOs. • 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 dif- ficult by power imbalances with better-resourced medical prac- tices. 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 manage- ment 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 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, PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 153 future scaling much be considered from the start. Adaptations that facili- tate integration in a single setting, such as a local adaptation of screen- ing 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 address- ing 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 have 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 document- ing 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 popula- tion (Purnell et al., 2018). Practices should also ensure that their staffing is adequate to support intended activities and that funding structures to support integration are in place. The practices will need to decide which patients are targeted for social needs screening, which social needs screen- ing 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 PREPUBLICATION COPY—Uncorrected Proofs

154 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH 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 chal- lenges, 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 under- standing 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 im- prove 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 informa- tion 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 (Ander- mann, 2018). • Provide well-designed workflows for social needs screening, con- sidering 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 logistics (Andermann, 2018; Gold et al., 2017, 2018; Joshi et al., 2018). • Demonstrate the utility of systematic, EHR-documented social needs screening. In several studies, practice staff said such screening helped them understand their patients’ needs, which increased PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 155 their acceptance of this practice. Such data can be used for ad- vocacy, risk stratification, and other purposes (Gold et al., 2018; Hewner et al., 2017; LaForge et al., 2018; Palacio et al., 2018; Tong et al., 2018). Analyze social needs data, and share it with clinic staff (Palacio et al., 2018). 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 con- ducted—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 con- ducting 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 work- flow 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 qual- ity improvement techniques, such as plan-do-study-act cycles, to test and improve social needs processes and workflows. This ap- proach in screening has been effective at supporting the adoption of social determinants into clinic workflows and health processes (Burkhardt et al., 2012; Pescheny et al., 2018). PREPUBLICATION COPY—Uncorrected Proofs

156 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE • Provide feedback data to show medical practice staff and leadership on progress in implementing social care integration (Pescheny et al., 2018). This strategy will be necessary—but not sufficient on its own—to support this integration. Check screening rates data often to inform workflow adaptations, and check in with high and low performers (Adams et al., 2017; Andermann, 2018; Bur- khardt et al., 2012; Katz et al., 2008; Knowles et al., 2018; Pescheny et al., 2018). Be sure to establish whether screened patients desire clinic-led social care intervention before taking action to provide such support (Gold et al., 2018; Pescheny et al., 2018). Implementation Strategies Targeting Community Partners Strategies that may help integration challenges experienced by CBOs are listed below. • Engage community stakeholders and partners from the start, includ- ing public health agencies and county or city counterparts who lead other social sector agencies, including in housing, food, transportation, and education; identify common ground and goals (Bonney and Chang, 2018; Joshi et al., 2018; Thomas-Henkel and Schulman, 2017; Udow-Phillips et al., 2018). • Start small, to address problems before expanding, and be realistic about the time needed (Pescheny et al., 2018; Udow-Phillips et al., 2018). • Train all partners in social care integration and about how the partnership will work (Pescheny et al., 2018). • Build trust by mutually setting clear goals and expectations at the start; by having staff from all partner organizations meet in person before implementation begins; by enabling regular, bidirectional communication, feedback, and collaborative prob- lem-solving; by using bottom-up approaches to alignment and partnership; and by being willing to revise how the partnership works (Joshi et al., 2018; Pescheny et al., 2018; Udow-Phillips et al., 2018; Valentijn et al., 2015). • Monitor partnership activities regularly to ensure that needed revi- sions are identified, goals are met, and no partner’s capacity is overtaxed (Bonney and Chang, 2018). • Establish a governance structure that describes leadership roles, which patients will be served, training requirements, financing and business processes, methods for measuring success, and legal aspects (Bonney and Chang, 2018; Pescheny et al., 2018; Udow- Phillips et al., 2018). Create a partnership agreement. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 157 • Establish the infrastructure needed for partnership activities, including staffing, start-up and maintenance funding, a monitoring and im- provement plan, data sharing (ideally through “closing the loop” between partners serving the same patient) (Bonney and Chang, 2018). • Consider different partnership structures, such as partnering with a single CBO that can link patients to an array of services, such as an aging and disability resource center or a medical–legal part- nership (Hyatt Thorpe et al., 2017; Klein et al., 2013; Martinez et al., 2017; Pettignano et al., 2012; Regenstein et al., 2018; Salter et al., 2018; Sandel et al., 2010; Sege et al., 2015; Williamson et al., 2018). Alternately, join or create a community-wide spoke-and- hub or pathways model, wherein patients are connected to many services through multiple entry points (AHRQ, 2016; Bonney and Chang, 2018; Hostetter and Klein, 2017). • Work with partnering agencies and organizations to identify funding structures that support social care integration; for example, some payers may require social needs screening and referrals, such as accountable care organizations (Amarasingham et al., 2018; An- dermann, 2018; Bachrach et al., 2014, 2018; Crumley and Marlise, 2018). These structures are discussed in detail in Chapter 5. • Share data with CBO partners, if possible in a way that is useful to the CBO. REFERENCES Adams, E., D. Hargunani, L. Hoffmann, G. Blaschke, J. Helm, and A. Koehler. 2017. Screen- ing for food insecurity in pediatric primary care: A clinic’s positive implementation experiences. Journal of Health Care for the Poor and Underserved 28(1):24–29. AHRQ (Agency for Healthcare Research and Quality). 2016. Pathways Community HUB Manual: A guide to identify and address risk factors, reduce costs, and improve outcomes. https://innovations.ahrq.gov/sites/default/files/Guides/CommunityHubManual. pdf (accessed May 24, 2019). Amarasingham, R., B. Kapoor, A. Karam, N. Nguyen, and B. Xie. 2018. Using community partnerships to integrate health and social services for high-need, high-cost patients. Issue Brief (The Commonwealth Fund) 2018:1–11. American Society on Aging. 2019. Aging and Disability Business Institute. https://www. asaging.org/aging-and-disability-business-institute-0 (accessed April 9, 2019). Andermann, A. 2018. Screening for social determinants of health in clinical care: Moving from the margins to the mainstream. Public Health Reviews 39:19. Bachrach, D., H. Pfister, K. Wallis, and M. Lipson. 2014. Addressing patients’ social needs: An emerging business case for provider investment. The Commonwealth Fund. https:// www.commonwealthfund.org/sites/default/files/documents/___media_files_ publications_fund_report_2014_may_1749_bachrach_addressing_patients_social_ needs_v2.pdf (accessed May 24, 2019). PREPUBLICATION COPY—Uncorrected Proofs

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IMPLEMENTATION CHALLENGES AND SOLUTIONS 159 Gottlieb, L., D. Hessler, D. Long, A. Amaya, and N. Adler. 2014. A randomized trial on screen- ing for social determinants of health: The iScreen study. Pediatrics 134(6):e1611–e1618. Gottlieb, L. M., K. J. Tirozzi, R. Manchanda, A. R. Burns, and M. T. Sandel. 2015. Moving elec- tronic medical records upstream: Incorporating social determinants of health. American Journal of Preventive Medicine 48(2):215–218. Griffin, K., C. Nelson, L. Realmuto, and L. Weiss. 2018. Partnerships between New York City health care institutions and community-based organizations. Greater New York Hospital Assocation and The New York Academy of Medicine. https://nyam.org/media/filer_ public/9f/5b/9f5b33a3-0795-4a1a-9b90-fa999e9ddf8e/hco_cbo_partnerships_digital. pdf (accessed May 24, 2019). Gunderson, J. M., M. L. Wieland, O. Quirindongo-Cedeno, G. B. Asiedu, J. L. Ridgeway, M. W. O’Brien, T. M. Nelson, R. Buzard, C. Campbell, and J. W. Njeru. 2018. Community health workers as an extension of care coordination in primary care: A community- based cosupervisory model. Journal of Ambulatory Care Management 41(4):333–340. Hamilton, A. B., A. N. Cohen, D. L. Glover, F. Whelan, E. Chemerinski, K. P. McNagny, D. Mullins, C. Reist, M. Schubert, and A. S. Young. 2013. Implementation of evidence‐ based employment services in specialty mental health. Health Services Research 48(6 Pt 2):2224–2244. Hewner, S., S. Casucci, S. Sullivan, F. Mistretta, Y. Xue, B. Johnson, R. Pratt, L. Lin, and C. Fox. 2017. Integrating social determinants of health into primary care clinical and in- formational workflow during care transitions. eGEMS 5(2):2. Hostetter, M., and S. Klein. 2017. In focus: Creating pathways and partnerships to address patients’ social needs. The Commonwealth Fund. June 21. https://www.commonwealthfund. org/publications/newsletter-article/2017/jun/focus-creating-pathways-and-partner- ships-address-patients (accessed May 24, 2019). Hripcsak, G., C. B. Forrest, P. F. Brennan, and W. W. Stead. 2015. Informatics to support the IOM social and behavioral domains and measures. Journal of American Medical Informat- ics Association 22(4):921–924. Hyatt Thorpe, J., L. Cartwright-Smith, E. Gray, and M. Mongeon. 2017. Information sharing in medical–legal partnerships: Foundational concepts and resources. National Center for Medical Legal Partnership at the George Washington University. https://medical- legalpartnership.org/wp-content/uploads/2017/07/Information-Sharing-in-MLPs. pdf (accessed May 24, 2019). Institute for Alternative Futures. 2012. Community health centers: Leveraging the social determinants of health. Alexandria, VA: Institute for Alternative Futures. http://www. altfutures.org/wp-content/uploads/2016/04/2012_Report_Community-Health- Centers-Leveraging-the-Social-Determinants-of-Health.pdf (accessed May 24, 2019). Jaganath, D., K. Johnson, M. M. Tschudy, K. Topel, B. Stackhouse, and B. S. Solomon. 2018. Desirability of clinic-based financial services in urban pediatric primary care. Journal of Pediatrics 202:285–290. Jani, J. S., C. Tice, and R. Wiseman. 2012. Assessing an interdisciplinary health care model: The Governor’s Wellmobile Program. Social Work in Health Care 51(5):441–456. Jensen, R. E., N. E. Rothrock, E. M. DeWitt, B. Spiegel, C. A. Tucker, H. M. Crane, C. B. For- rest, D. L. Patrick, R. Fredericksen, L. M. Shulman, D. Cella, and P. K. Crane. 2015. The role of technical advances in the adoption and integration of patient-reported outcomes in clinical care. Medical Care 53(2):153–159. Joshi, K., S. Smith, S. D. Bolen, A. Obsborne, M. Benko, and E. Trapl. 2018. Implementing a produce prescription program for hypertensive patients in safety net clinics. Health Promotion and Practice 20(1):94–104. Katz, K. S., S. M. Blake, R. A. Milligan, P. W. Sharps, D. White, B., M. F. Rodan, M. Rossi, and K. B. Murray. 2008. The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among preg- nant African American women. BMC Pregnancy and Childbirth 8(1):22. PREPUBLICATION COPY—Uncorrected Proofs

160 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE Klein, M. D., A. F. Beck, A. W. Henize, D. S. Parrish, E. E. Fink, and R. S. Kahn. 2013. Doctors and lawyers collaborating to help children: Outcomes from a successful partnership between professions. Journal of Health Care for the Poor & Underserved 24(3):1063–1073. Knowles, M., S. Khan, D. Palakshappa, R. Cahill, E. Kruger, B. Poserina, G., B. Koch, and M. Chilton. 2018. Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings. Journal of Health Care for the Poor and Underserved 29(1):181–191. Kunkel, S. R., A. Lackmeyer, J. K. Straker, and T. L. Wilson. 2018. Community-based organi- zations and health care contracting: Building & strengthening partnerships. Scripps Ger- ontology Center research brief. https://sc.lib.miamioh.edu/bitstream/handle/2374. MIA/6280/Kunkel-Community-Based-Organizations-and-Health-Care-Contracting. pdf (accessed May 24, 2019). LaForge, K., R. Gold, E. Cottrell, A. E. Bunce, M. Proser, C. Hollombe, K. Dambrun, D. J. Cohen, and K. D. Clark. 2018. How 6 organizations developed tools and processes for social determinants of health screening in primary care: An overview. Journal of Ambula- tory Care Management 41(1):2–14. Lewis, J. H., K. Whelihan, I. Navarro, and K. R. Boyle. 2016. Community health center pro- vider ability to identify, treat and account for the social determinants of health: A card study. BMC Family Practice 17:121. Lohr, A. M., M. Ingram, A. V. Nunez, K. M. Reinschmidt, and S. C. Carvajal. 2018. Commu- nity–clinical linkages with community health workers in the United States: A scoping review. Health Promotion Practice 19(3):349–360. Martinez, O., J. Boles, L.-M. Munoz, E. C. Levine, C. Ayamele, R. Eisenberg, J. Manusov, and J. Draine. 2017. Bridging health disparity gaps through the use of medical legal partnerships in patient care: A systematic review. Journal of Law, Medicine & Ethics 45(2):260–273. Meredith, L. S., G. Azhar, A. Okunogbe, I. A. Canelo, J. E. Darling, A. E. Street, and E. M. Yano. 2017. Primary care providers with more experience and stronger self-efficacy beliefs regarding women veterans screen more frequently for interpersonal violence. Women’s Health Issues 27(5):586–591. Monsen, K. A., J. M. Rudenick, N. Kapinos, K. Warmbold, S. K. McMahon, and E. N. Schorr. 2018. Documentation of social determinants in electronic health records with and without standardized terminologies: A comparative study. Proceedings of Singapore Healthcare 28(1):39–47. Nelson, E. C., E. Eftimovska, C. Lind, A. Hager, J. H. Wasson, and S. Linblad. 2015. Patient reported outcome measures in practice. BMJ 350:g7818. Nguyen, O. K., R. T. Higashi, A. N. Makam, J. C. Mijares, and S. C. Lee. 2018. The influ- ence of financial strain on health decision-making. Journal of General Internal Medicine 33(4):406–408. O’Gurek, D. T., and C. Henke. 2018. A practical approach to screening for social determinants of health. Family Practice Management 25(3):7–12. Olayiwola, J. N., R. Willard-Grace, K. Dubé, D. Hessler, R. Shunk, K. Grumbach, and L. Got- tlieb. 2018. Higher perceived clinic capacity to address patients’ social needs associated with lower burnout in primary care providers. Journal of Health Care for the Poor and Underserved 29(1):415–429. Palacio, A., D. Seo, H. Medina, V. Singh, M. Suarez, and L. Tamariz. 2018. Provider perspec- tives on the collection of social determinants of health. Population Health Management 21(6):501–508. Pescheny, J. V., Y. Pappas, and G. Randhawa. 2018. Facilitators and barriers of implementing and delivering social prescribing services: A systematic review. BMC Health Services Research 18(1):86. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION CHALLENGES AND SOLUTIONS 161 Pettignano, R., S. B. Caley, and S. McLaren. 2012. The health law partnership: Adding a lawyer to the health care team reduces system costs and improves provider satisfaction. Journal of Public Health Management & Practice 18(4):E1–E3. Pinto, A. D., G. Glattstein-Young, A. Mohamed, G. Bloch, F. H. Leung, and R. H. Gla- zier. 2016. Building a foundation to reduce health inequities: Routine collection of sociodemographic data in primary care. Journal of the American Board of Family Medicine 29(3):348–355. Proctor, E. K., B. J. Powell, and J. C. McMillen. 2013. Implementation strategies: Recommen- dations for specifying and reporting. Implementation Science 8:139. Purnell, T. S., J. Kimbrough Marshall, I. Olorundare, R. W. Stewart, S. Sisson, B. Gibbs, L. S. Feldman, A. Bertram, A. R. Green, and L. A. Cooper. 2018. Provider perceptions of the organization’s cultural competence climate and their skills and behaviors targeting patient-centered care for socially at-risk populations. Journal of Health Care for the Poor and Underserved 29(1):481–496. Quinn, C., K. Johnson, C. Raney, J. Baker, K. Topel, M. M. Tschudy, D. Jaganath, and B. S. Solomon. 2018. “In the clinic they know us”: Preferences for clinic-based financial and employment services in urban pediatric primary care. Academic Pediatrics 18(8):912–919. Regenstein, M., J. Trott, A. Williamson, and J. Theiss. 2018. Addressing social determinants of health through medical–legal partnerships. Health Afffairs (Millwood) 37(3):378–385. Ridgeway, J. L., T. J. Beebe, C. G. Chute, D. T. Eton, L. A. Hart, M. H. Frost, D. Jensen, V. M. Montori, J. G. Smith, S. A. Smith, A. D. Tan, K. J. Yost, J. Y. Ziegenfuss, and J. A. Sloan. 2013. A brief patient-reported outcomes quality of life (PROQOL) instrument to improve patient care. PLOS Medicine 10(11):PMC3825652. Rogers, E. A., S. Turcotte Manser, J. Cleary, A. M. Joseph, E. M. Harwood, and K. T. Call. 2018. Integrating community health workers into medical homes. Annals of Family Medicine 16(1):14–20. Saberi, E., N. Eather, S. Pascoe, M.-L. McFadzean, F. Doran, and M. Hutchinson. 2017. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australasian Emergency Nursing Journal 20(2):82–86. Salter, A. S., G. T. Anderson, J. Gettinger, and S. Stigleman. 2018. Medical–legal partnership in western North Carolina. North Carolina Medical Journal 79(4):259–260. Sandel, M., M. Hansen, R. Kahn, E. Lawton, E. Paul, V. Parker, S. Morton, and B. Zuckerman. 2010. Medical–legal partnerships: Transforming primary care by addressing the legal needs of vulnerable populations. Health Affairs (Millwood) 29(9):1697–1705. Saxe-Custack, A., H. C. Lofton, M. Hanna-Attisha, C. Victor, G. Reyes, T. Ceja, and J. LaChance. 2018. Caregiver perceptions of a fruit and vegetable prescription programme for low-income paediatric patients. Public Health Nutrition 21(13):2497–2506. Sege, R., G. Preer, S. J. Morton, H. Cabral, O. Morakinyo, V. Lee, C. Abreu, E. De Vos, and M. Kaplan-Sanoff. 2015. Medical–legal strategies to improve infant health care: A random- ized trial. Pediatrics 136(1):97–106. Stehlik, J., C. Rodriguez-Correa, J. A. Spertus, J. Biber, J. Nativi-Nicolau, S. Zickmund, B. A. Steinberg, D. C. Peritz, A. Walker, J. Hess, S. G. Drakos, A. G. Kfoury, J. C. Fang, C. H. Selzman, and R. Hess. 2017. Implementation of real-time assessment of patient- reported outcomes in a heart failure clinic: A feasibility study. Journal of Cardiac Failure 23(11):813–816. Tan, Z. S., L. Jennings, and D. Reuben. 2014. Coordinated care management for dementia in a large academic health system. Health Affairs (Millwood) 33(4):619–625. Thomas, B., S. Fitzpatrick, S. Sidani, and E. Gucciardi. 2018. Developing and implementing a food insecurity screening initiative for adult patients living with type 2 diabetes. Canadian Journal of Diabetes 42(3):257–262. PREPUBLICATION COPY—Uncorrected Proofs

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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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