Navigating the journey from hospital to help: Family perspectives on overcoming barriers to connecting with resources to address social needs

OBJECTIVES: Recognizing the impact of social needs on childhood health outcomes, hospitals have implemented successful screening programs but struggle with connecting patients to community resources. We aimed to understand the barriers families face in getting help for their social needs after hospital discharge. 

METHODS: We conducted semistructured interviews with English- and Spanish-speaking caregivers of hospitalized children with social needs at a quaternary care hospital between October 2024 and January 2025 to understand caregivers' experiences in being referred from the hospital for social needs to community organizations including barriers they experienced in connecting with resources and their recommendations on overcoming these barriers. Fluent Spanish speakers interviewed the caregivers and recorded the interviews; interviews were professionally transcribed and analyzed thematically. 

RESULTS: Twenty-five participants were majority mothers and Spanish speaking with Medicaid insurance. Themes were grouped into (1) barriers families experienced in connecting with resources for their social needs after hospital discharge, including feeling overwhelmed, slow resource access, poor communication, and referrals and resources that do not match the families' needs, and (2) recommendations for overcoming barriers to resource connection including providing social needs care that is humanistic, longitudinal, and timely and matches the families' needs. Spanish-speaking caregivers recommended matching their need to overcome language barriers through providing hands-on and in-person support. 

CONCLUSION: Families with social needs desired continued support after hospital discharge to overcome barriers to resource connection, and Spanish-speaking caregivers recommended more hands-on and in-person support. Findings inform understanding around providing the appropriate degree of social needs support to facilitate resource connection after hospital discharge.