738 - Barriers and Facilitators to Implementing Health-Related Social Needs Screening and Referrals in the Bronx

Publication Number: 738.3756

Priya E. George, Albert Einstein College of Medicine, Bronx, NY, United States; Jessica Haughton, Albert Einstein College of Medicine, Bronx, NY, United States; Renee Whiskey, Albert Einstein College of Medicine, Bronx, NY, United States; Samantha Levano, Albert Einstein College of Medicine, BRONX, NY, United States; Hemen S. Muleta, Albert Einstein College of Medicine, New York City, NY, United States; Kevin Fiori, Albert Einstein College of Medicine, Bronx, NY, United States

Background: Pediatric health systems are recognizing the importance of identifying social determinants by implementing health-related social needs (HRSNs) screenings in clinical care. Our institution integrated Community Health Workers (CHWs) to provide support in addressing identified needs.

Objective: This study aimed to identify barriers and facilitators to HRSNs referrals and the integration of CHWs within outpatient clinical teams. This is the first study to explore clinician and CHW perspectives on social needs screening and navigation using CHWs in a large health system.

Design/Methods: This qualitative study explored perspectives from CHWs (3), program staff (3), and clinicians (4) at ambulatory care centers including internal medicine and pediatrics. Semi-structured interview guides were based on the 2022 Consolidated Framework for Implementation Research. Interviews were conducted via Zoom (November 2023-February 2024), audio-recorded, and transcribed. Two analysts independently coded transcripts, reconciling discrepancies using rapid qualitative methodology. Themes were identified using matrix tools and analytic memoing.

Results: Numerous salient themes were identified as facilitators: CHWs believe that effective framing of the CHW role by clinicians during patient visits likely led to increased acceptance of referrals by families. Clinicians believe CHW integration into the clinical space improves continuous clinician education on CHW utilization. Program staff cited strong leadership, clear role delineation, and high levels of clinician interaction with CHWs leading to successful workflows.

Key themes were identified as barriers: Despite strong support for CHWs, clinicians experience time constraints during visits, likely leading to missed referrals and insufficient patient discussions about CHWs. Clinicians cited misunderstandings on CHW versus social worker referrals and poor clinical integration of CHWs. Clinicians admitted to missing team meetings regarding CHW communications. Program staff believe a power dynamic exists between CHWs and clinicians, likely leading to CHWs feeling unable to advocate for themselves when receiving inappropriate referrals. CHWs find that sites with high staff turnover are challenging to continually re-educate. CHWs experience limitations in timely patient follow-up after the referral resulting in delayed patient contact likely leading to families declining assistance.

Conclusion(s): Enhancing CHW integration into clinical teams is crucial for addressing HRSNs in pediatric populations. This study provides insights for improving CHWs’ role in assisting families with HRSNs.

Figure 1. Community Health Worker Institute (CHWI) Health-related social needs screening to CHW referral process
The CHWI identifies and connects patients with HRSN to CHWs who assist in addressing social needs. After a positive HRSN screening, clinicians assess patient interest in assistance. With consent, an electronic referral is made in the electronic medical record (EMR) to a CHW. CHWs conduct an initial evaluation to gather demographic data and assess HRSNs. They connect patients to community resources and assist with benefit applications, maintaining communication until social needs are resolved or services are no longer needed.


Table 1. Participant Demographics (n=10)
Table 1 summarizes the descriptive characteristics of participants (n=10). All participants were female with an average work history of 57.1 months. Participants were on average 34 years old with a range of educational levels, MD being the highest (40%).