From screening to referral: Connecting heart transplant patients with resources to meet social needs remains challenging despite adequate support

Background: Screening for social needs has become increasingly common across healthcare settings. While pediatric programs across the United States have successfully implemented social needs in a clinic setting, the ability to connect families with a positive screen to needed resources is not entirely clear. Through this quality improvement initiative, we sought to universally screen for social needs and refer all families with a positive screen to community resources. 

Methods: Social needs screening was conducted within a pediatric heart transplant clinic in the Western USA. The clinic team devised two separate resource referral pathways: high-risk needs (addressed by social worker) and low-risk needs (referred to Unite Us). Referral outcomes of interest were resource identification and resource connection, with the social worker pathway demonstrating higher effectiveness. 

Results: Social needs screening identified 66 active needs among 28 of the 86 families screened. Team members were unable to identify a community resource for almost half of the identified needs (n = 30, 44.8%), most often because a resource was not found (n = 23). Of the 59 needs addressed, the clinic team was able to connect families to resources for 24 needs. Overall, families were connected to resources for 36.4% of all identified needs. 

Conclusions: Screening for social needs revealed a high degree of social need. However, referral to resources was hampered by two key barriers—lack of available resources and lack of local program follow-up. When resources were identified, the in-person support and referral pathway was more effective than remote support.