Addressing social needs in health care delivery can help achieve better health outcomes

Addressing social needs as a part of health care delivery can help achieve better health outcomes and potentially address major challenges in the United States health care system, according to a recently published consensus report by the National Academies of Sciences, Engineering and Medicine (NASEM).

The report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health, suggests five types of activities that health care systems can implement to incorporate social care into health care delivery, along with a framework for and guidance in the integration of these activities. The report defines social care as activities that address health-related social risk factors and social needs and describes social workers in particular as members of health care teams who are also specialists in social care.

In order to achieve better and more equitable health outcomes, addressing social factors such as housing, healthy food options, education, safety and employment in health care delivery - the economic and social conditions that influence differences in health outcomes - is essential to help address inequities in health and wellbeing. In this report we outline several recommendations for how this can be achieved."

Robyn Golden, LCSW, associate vice president of population health and aging at Rush University Medical Center

Golden served on the NASEM committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation's Health, which issued the report.

The report outlines recommendations on how to achieve the following goals:

  1. Design health care delivery to integrate social care, guided by five types of health care system activities: awareness, adjustment, assistance, alignment and advocacy.
  2. Build a workforce to integrate social care into health care delivery, with an emphasis on the role of clinical social workers in identifying and addressing complexities related to social risk factors and social needs.
  3. Develop a digital infrastructure that connects and aligns health care and social care organizations.
  4. Finance the integration of health care and social care, and support adequate funding for social care and community-based organizations to meet any increases in demand that comes from increased awareness of need.
  5. Fund, conduct, and translate research and evaluation on the effectiveness and implementation of social care integration practices in health care settings.

"It was truly gratifying to participate in this consensus report and work with prominent, nationally-recognized professionals from across the health care spectrum," said Golden. "As the study articulates, health systems do have a role to play in terms of carrying out activities to identify and support patients' social care needs – and to invest in communities to minimize the needs in the first place. In a nod to the significant efforts of Rush in this realm, the committee highlighted multiple projects at Rush that address the social aspects of our patients' lives."

Rush's interventions highlighted in the report include:

  • The Bridge Model of transitional care, an intervention developed in partnership with several community-based organizations and now disseminated across the country that includes comprehensive assessment and care planning, and engages home- and community-based services after hospital discharge
  • The Ambulatory Integration of the Medical and Social (AIMS) model that integrates social work care management into primary care and outpatient specialty care to identify patient and caregiver priorities and address social and mental health needs
  • "Anchor mission" activities that help combat disparities in outcomes on the West side of Chicago by investing in communities, including the West Side United initiative

Golden is co-director of the Center for Health and Social Care Integration (CHaSCI), which has sought new and creative care models that help address complex social issues that harm the health and wellness of patients, families, and communities. CHaSCI also led the organizing efforts for the study in partnership with several leaders in social work practice, research, and education. The evidence related to Rush's social care models was a key catalyst for building support for the study. The study and summary materials can be accessed at the National Academies website. To learn more about CHaSCI's activities to disseminate and build on the report, email [email protected]

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