Forming community partnerships to create social needs referral programs

Two pediatric hospitalist groups both struggle with connecting patients to community resources to address their health-related social needs (HRSNs). Pediatric hospitalist group “A” successfully increases the percentage of patients receiving an automated list of community-based resources for patients with HRSNs. Pediatric hospitalist group “B” joins a community advisory board (CAB) composed of families with HRSNs, community-based organizations (CBOs), and the local health department. The CAB meets monthly to discuss issues with community resource connection. After a year, the group agrees to trial an intervention to improve community resource connection for pediatric patients after hospital discharge.

Below, we describe our successes and failures in proactively applying key aspects of the CBPR framework to our hospital-community partnership to address community resource connection.