Pathways to success in meeting health-related social needs

The pathways strategy provides a framework that can be used prospectively by health care organizations in developing effective programs to meet the unique health-related social needs of their populations by engaging with community-based organizations, intended program participants, and other stakeholders. This article outlines an approach to understand and improve whether and how social drivers of health (SDOH) programs connect participants with resources to address their health-related social needs (HRSNs). In this article, the authors focus on a predominant SDOH program model in which activities are initiated within a health care organization. The article proposes a pathways strategy to appreciate, synthesize, and manage the ecosystem in which an SDOH program operates and the pathways by which program participants do or do not get connected to social resources that meet their needs. The value of this approach for retrospective analysis of program effectiveness is shown in examples from programs addressing a variety of HRSNs. Of note, the pathways strategy also is a promising prospective tool for SDOH program design and improvement. The pathways strategy requires an understanding of the ecosystem in which an SDOH program operates: the actors, factors, and relationships that influence its capacity and results. The strategy calls for: (1) engaging all stakeholders, including the program participants (patients, clients, and members), to share their perspectives during design and evaluation of the pathway; (2) being grounded in an understanding of the ecosystem, determining the program goals, and mapping step-by-step pathways by which a patient with unresolved HRSNs has those needs successfully met; (3) mitigating potential drop-offs by strengthening the pathway to connect more people with resources; and (4) measuring the connection success rate at each step along the pathway and using process and qualitative analysis to improve pathway connections. The road map in this article outlines the value of proactively addressing preventable weaknesses in the creation and execution of programs that — through a systematic, iterative approach — will reflect the needs of the community and program participants and result in improved clinical and social outcomes.