Social Worker and Community Health Worker Collaboration in Addressing Social Needs

BACKGROUND AND OBJECTIVES: Recent regulations require that hospitals screen families for health-related social needs (HRSNs), but many hospitals lack the resources and infrastructure to address these needs. Social workers (SWs) and community health workers (CHWs) play a critical role in filling this gap. We aimed to understand SW and CHW perspectives regarding effective strategies for addressing HRSNs during and after inpatient pediatric hospitalizations. METHODS: We conducted semi-structured interviews with inpatient SWs and CHWs at 3 academic children’s hospitals exploring participants’ experiences connecting families with resources, communicating with medical teams, and facilitating continued support for families after hospital discharge. Interviews were recorded, transcribed, and coded; themes were derived using thematic analysis. RESULTS: We interviewed 28 participants (19 SWs, 9 CHWs). We then identified 4 themes (and 5 subthemes): (1) engagement with caregivers (SWs and CHWs aim to balance providing resources and promoting families’ self-sufficiency), (2) approach to addressing needs (SWs and CHWs have complementary skillsets, and they find maintaining updated resource repositories a significant challenge), (3) engagement with medical teams (communication with providers focuses on needs impacting medical care or discharge planning), and (4) approach to follow-up (ensuring families have continued support following hospital discharge is a challenge, particularly for select populations). CONCLUSIONS: SWs and CHWs offer synergistic and complementary expertise to support families experiencing HRSNs. Participants highlighted opportunities to optimize processes for updating resource repositories and improve longitudinal support for families following hospital discharge.