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

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

• 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

TABLE 6-1
Potential Strategies for Initiating Social Care Integration

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

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

• 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.
  • When will social needs screening occur? Timing challenges include the difficulty and time-consuming nature of reaching some patients, ensuring accessibility of social needs information 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).
  • How will social needs screening be administered? There is little evidence to indicate which data collection mode patients prefer (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 (e.g., 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 screening 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 schedules, turnover may necessitate finding and training replacements, 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 curriculum, identifying appropriate educational methodologies, selecting 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 documentation, 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 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

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.

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

(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

TABLE 6-5
Potential Strategies for External Referrals

NOTE: CBO = community-based organization.

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).

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).

• 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

• • inequalities. Practices may not understand how their partnership 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).

  • 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 exacerbated 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.
  • 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; Institute for Alternative Futures, 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 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

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

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

• 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 their acceptance of this practice. Such data can be used for advocacy, 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 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

• improvement techniques, such as plan-do-study-act cycles, to test and improve social needs processes and workflows. This approach 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).

• 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; Burkhardt 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, including 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 problem-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 revisions 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.
• Establish the infrastructure needed for partnership activities, including staffing, start-up and maintenance funding, a monitoring and improvement plan, and 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 partnership (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; Andermann, 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.

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