NUR 653 Module 4 Social Needs Paper Example

Screening for Health-Related Social Needs and What Community Health Workers Can Do About Them

[Student Name]

Southern New Hampshire University

NUR 653: Population Care Management

Module Four Social Needs Paper

[Instructor Name]

[Date]

Screening for Health-Related Social Needs and What Community Health Workers Can Do About Them

A patient whose A1c remains above 10% despite three medication changes may not need a fourth drug. She may need a way to afford food that does not come from a convenience store, a ride to the pharmacy or a stable place to keep insulin cold. Health care organizations increasingly screen patients for these social needs, but screening raises its own question: what happens after a patient says yes? Mesa Valley, the composite ACO in these samples, piloted social needs screening in two of its eleven practices over six months. This paper describes the framework used, reports the pilot's findings and problems, reviews evidence on what can be done for patients with social needs and recommends how the organization should proceed. It argues that screening is worthwhile only when paired with a reliable way to help, and that community health workers are the strongest option the evidence supports.

Why Social Needs Belong in Population Care

Braveman and Gottlieb (2014) drew together decades of research to argue that income, education, housing, neighborhood conditions and working conditions shape health powerfully, both directly and through their effects on behaviors, stress and access to resources. They described these upstream conditions as the causes of the causes of disease. For a population care program, the implication is practical: a program that addresses only clinical factors will reach a ceiling for patients whose social circumstances make it hard to follow a treatment plan. Medications that are unaffordable, appointments that require unavailable transportation and diets that depend on food a family cannot buy all limit what clinical care can achieve.

The Screening Framework

Alley et al. (2016) described the Accountable Health Communities model, a federal Medicare and Medicaid demonstration built to learn whether identifying and addressing the health-related social needs of beneficiaries could reduce costs and improve outcomes. The model screens for five core domains: housing instability, food insecurity, transportation problems, difficulty paying utility bills and interpersonal safety. It tested three levels of response: raising awareness of community resources, providing navigation to help patients obtain them and aligning community services so that resources match needs. Mesa Valley adopted the model's ten-item screening tool because it is brief, has been used widely and covers the domains most relevant to chronic disease management.

What the Pilot Found

Over six months, medical assistants offered screening to adult patients at routine visits in two practices, and 1,420 patients completed it. Of these, 36% reported at least one need: 21% food insecurity, 15% transportation problems, 13% difficulty paying utilities, 11% housing instability and 3% concerns about safety. Among patients with diabetes, the proportion with at least one need was 44%, and patients reporting a need were overrepresented among those with A1c values over 9%.

The pilot also exposed problems. Positive screens generated a printed list of community resources, and patients were asked to call the agencies themselves. When the population care manager called a sample of 100 patients a month later, only 18 had received help from the referral, and many had not called because of limited phone minutes, confusion about eligibility or doubts that it would help. Several medical assistants reported feeling uncomfortable asking about safety without a clear plan if a patient disclosed abuse. And the two practices had no way to learn whether a referral had succeeded.

What Community Health Workers Achieved

The pilot's results match a broader lesson: handing patients a list is not enough. Kangovi et al. (2017) conducted a randomized trial of the IMPaCT community health worker model among low-income patients with two or more chronic conditions in Philadelphia. Community health workers, hired for their shared life experience with patients and trained to provide tailored social support, navigation and advocacy, worked with patients for six months. Compared with usual care, patients who received community health worker support reported better mental health and higher quality of primary care and spent fewer total days in the hospital, including fewer repeat readmissions. The model's strength lay in relationships: community health workers helped patients set their own goals and addressed the barriers that mattered most to them.

Recommendations

Mesa Valley should continue screening but only where there is a way to act on the results. First, the organization should hire four community health workers from the communities its practices serve, beginning with the two rural practices where diabetes control is poorest, and train them in a structured model such as IMPaCT. Patients with a positive screen and a chronic condition will be offered community health worker support rather than a resource list. Second, referrals should be closed-loop: the community health worker or navigator makes the connection with the agency, confirms whether help was received and records the result in the patient's record. Third, safety concerns require a clear protocol, including a private setting, a warm handoff to a trained social worker and resources for domestic violence, before any medical assistant asks the question. Fourth, the organization should share aggregate screening data with community partners, such as the regional food bank and transit authority, to align services with the needs identified.

Measurement

The expanded program will track screening rates, the proportion of patients with needs who accept community health worker support, the proportion of referrals confirmed as resolved and, for patients with diabetes, changes in A1c, visit gaps and hospital days. Patients will be asked whether they found the screening respectful and the help useful. The target for confirmed resolution of referrals is 60% within ninety days, compared with the pilot's 18%.

Conclusion

Social needs are common in Mesa Valley's population and closely tied to poor diabetes control, and the pilot showed that screening followed by a resource list rarely helps. The Accountable Health Communities framework offers a practical screening tool, and the IMPaCT trial shows that community health workers can improve patients' experiences and reduce hospital use. Pairing screening with community health workers, closed-loop referrals, a safety protocol and community partnerships turns a question on a form into help a patient can use.

References

Alley, D. E., Asomugha, C. N., Conway, P. H., & Sanghavi, D. M. (2016). Accountable health communities: Addressing social needs through Medicare and Medicaid. New England Journal of Medicine, 374(1), 8-11. https://doi.org/10.1056/NEJMp1512532

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Kangovi, S., Mitra, N., Grande, D., Huo, H., Smith, R. A., & Long, J. A. (2017). Community health worker support for disadvantaged patients with multiple chronic diseases: A randomized clinical trial. American Journal of Public Health, 107(10), 1660-1667. https://doi.org/10.2105/AJPH.2017.303985