The impact of a bidirectional clinic to community social care referral program

BACKGROUND: Practical knowledge of how to address patients' social needs could have a large health impact. 

OBJECTIVE: Describe a scalable electronic health record (EHR)-facilitated, clinic-to-community linkage (CCL) program that addresses social needs at 6 clinics in 4 health systems. 

RESEARCH DESIGN: Primary care teams referred eligible patients to United Way 211 (UW 211) via a point-of-care EHR referral between 2018 and 2023. Patients were eligible if they were adults with uncontrolled blood pressure or blood sugar or 2-17 years old with overweight/obesity or asthma. UW 211 referred patients to assess and connect them with community resources and provided electronic feedback to the EHR. We conducted descriptive analyses of process measures (eg, patients referred, needs identified, need resolution). We then conducted pre-post analyses of selected health outcomes (ie, blood pressure, weight, and asthma exacerbations) versus comparison clinics. 

RESULTS: Referral ranges varied by clinic from 3% to 43%, with 1224 total patients referred and 38% (n=461) reached by UW 211. All 461 had at least one need, and 87% (n=400) had one need resolved or a resolution in progress. Reached patients had an average of 2.9 (SD 1.3) needs and an average of 10.1 resource referrals provided (SD 6.1). Top needs included food, physical activity, housing and utilities. No differences were found pre to post within the intervention clinics except for improvements in blood pressure control. However, comparison clinics had greater improvements in blood pressure control during the same time frame. 

CONCLUSIONS: An EHR-facilitated, closed-loop CCL program to address patients' social needs is feasible. Further research on the comparative effectiveness and sustainability of models to address social needs will be critical in advancing health equity.