Implementing a social needs screening and referral program for obstetrics and gynecology patients

Background: Health-related social needs (HRSNs) contribute to poor obstetrics and gynecology (OB/GYN) outcomes. Community health worker (CHW) interventions are a promising model for connecting patients with social resources, improving patient outcomes, and advancing health equity; however, limited research exists evaluating such interventions in OB/GYN practices. Objective: We aimed to describe the implementation of a novel program for OB/GYN patients that included standardized HRSN screening and referral to CHWs. 

Study Design: This was a retrospective cohort study of patients seen by CHW-supported OB/GYN clinical practices who completed a standardized HRSN screener between June 2022 and May 2024. Patients who were screened and/or self-reported unmet HRSNs were eligible for referral to CHWs by their clinician. We used descriptive statistics to assess RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes and sociodemographic characteristics of patients. 

Results: Of 11,191 OB/GYN patients screened, 1,871 (16.7%) reported unmet HRSNs. There were 944 patients with outreach attempted by CHWs, of whom 696 (73.7%) consented to work with CHWs. Overall, 93.5% of patients were connected or equipped to connect to social services and 92.7% reported improvement or resolution of HRSNs. Referral rates varied by clinical team (median 22.3%, IQR 15.5–30.9%), with a median of 8 days (IQR 3–19 days) between referral and first CHW contact. The median annual program cost per patient was $289.07 (IQR $230.17–$431.91). 

Conclusion: This HRSN screening and referral program was highly effective in connecting referred OB/GYN patients with unmet HRSNs to relevant social services. Addressing patients’ unmet HRSNs may allow patients to better engage in OB/GYN care and improve clinical outcomes.