A formative evaluation of social care integration across a safety-net health system

Insights based on an analysis of 175 qualitative semi-structured interviews with health care patients, frontline providers, and executives across the public health care system of Los Angeles County are offered as considerations to support the provision of meaningful assistance for unmet social needs in health care settings through coordination, operational thinking, and intentional implementation plans. Recognizing that social determinants of health influence patient outcomes, health systems increasingly look to integrate social care into clinical spaces. Although ample research addresses screening for unmet social needs, how social care integration is operationalized in large health systems remains largely undescribed. In an effort to complete a formative evaluation of social care integration across a large urban safety-net health system, researchers performed qualitative semi-structured interviews to assess baseline levels of social care integration and barriers and facilitators to social care delivery in multiple clinical settings (primary care, ED, inpatient, and specialty care) across the Los Angeles County Department of Health Services. They used the Consolidated Framework for Implementation Research to categorize implementation across disparate settings and the National Academies of Sciences, Engineering, and Medicine model of health system activities to integrate social care as the social determinants framework. Data were analyzed by using both an inductive and deductive approach. The authors interviewed 175 stakeholders (112 frontline providers, 32 executives, and 31 patients) across 4 hospitals, health system administration, and the ambulatory care network. Frontline providers included physicians, registered nurses, social workers, medical assistants, community health workers, and registration workers. Participants described 30 unique social care initiatives across the system that address needs in the areas of housing, food insecurity, employment, legal needs, material needs, financial needs, violence, and immigration status. All stakeholder groups reported that they believe helping patients with unmet social needs is aligned with the mission of the health system. True integration, however, has not yet occurred because social care remains widely considered an add-on rather than a core function of health care delivery, study participants report. Respondents say that social care integration is not on the agenda of their organizations’ operational committees; thus, entry into the available social care programs remains uncoordinated and the care fragmented. The authors’ findings show that in this large safety-net health system — which has both a patient population with high levels of unmet social needs and a vast array of social care programming — social care delivery is hindered by lack of strategy and coordination. The health care delivery lens of right care, right place, right time must be applied to social care integration to improve coordination between programs and to maximize efficiency.