@article{c6c0085f36fb4704b20d99c57fa6cbf7,
title = "Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program",
abstract = "Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.",
keywords = "community health workers, implementation science, primary care, social determinants of health, social needs",
author = "Fiori, {Kevin P.} and Rehm, {Colin D.} and Dana Sanderson and Sandra Braganza and Amanda Parsons and Tashi Chodon and Renee Whiskey and Patrizia Bernard and Rinke, {Michael L.}",
note = "Funding Information: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Doris Duke Charitable Foundation (#2018169) and the National Institutes of Health/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore Clinical and Translational Research (UL1TR001073), with REDCap funding from the Harold and Muriel Block Institute for Clinical and Translational Research at Einstein and Montefiore (1UL1TR002556). Funding Information: The authors would like to acknowledge the role of many CLC program partners including team members from the Montefiore Office of Community and Population Health; Montefiore Medical Group leadership and analytics team for developing the screening tool, integrating it within the electronic medical record, and providing screening data for performance improvement activities; BCHN Division of Programs team for recruiting, training, managing, and shepherding a skilled and insightful team of CHWs; and the staff and patients at the Comprehensive Health Care Center for supporting this new initiative. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Doris Duke Charitable Foundation (#2018169) and the National Institutes of Health/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore Clinical and Translational Research (UL1TR001073), with REDCap funding from the Harold and Muriel Block Institute for Clinical and Translational Research at Einstein and Montefiore (1UL1TR002556). Publisher Copyright: {\textcopyright} The Author(s) 2020.",
year = "2020",
month = jun,
day = "1",
doi = "10.1177/0009922820908589",
language = "English (US)",
volume = "59",
pages = "547--556",
journal = "Clinical Pediatrics",
issn = "0009-9228",
publisher = "SAGE Publications Inc.",
number = "6",
}
