Forming Community Partnerships to Create Social Needs Referral Programs

Two pediatric hospitalist groups both struggle with connecting patients to community resources to address their health-related social needs (HRSNs). Pediatric hospitalist group “A” successfully increases the percentage of patients receiving an automated list of community-based resources for patients with HRSNs. Pediatric hospitalist group “B” joins a community advisory board (CAB) composed of families with HRSNs, community-based organizations (CBOs), and the local health department. The CAB meets monthly to discuss issues with community resource connection. After a year, the group agrees to trial an intervention to improve community resource connection for pediatric patients after hospital discharge.These two scenarios describe different mental models for approaching HRSNs. Mental models are perceptions of how pediatric hospitalists and communities could interact.1 Hospital-driven mental models follow a more traditional experimental design approach whereby the hospital chooses the interventions and outcomes of an improvement project and takes a top-down approach to implementation, such as the model presented by group “A.”2 The inpatient team may not involve the community at all or may ask a CAB for approval of the inpatient team’s research or quality improvement plan, but there is no true co-design of interventions.2 Community-driven mental models emphasize equitable partnerships whereby hospital partners defer to community expertise regarding the causes, potential solutions, and outcomes of community health problems, such as the model presented by group “B.”3One evidenced-based framework for forming equitable community partnerships comes from the Community-Based Participatory Research (CBPR) conceptual model.3 Although the American Academy of Pediatrics (AAP) has recommended forming equitable partnerships with community stakeholders to address the HRSNs of children, application of the CBPR framework to address the HRSNs of hospitalized children is lacking.4–6 Below, we describe our successes and failures in proactively applying key aspects of the CBPR framework to our hospital-community partnership to address community resource connection.A community-driven mental model begins with establishing community trust and a shared mission based on the CBPR framework for building equitable community relationships.3 In our local context, a CAB called “Model Community” was established in 2022 with a shared mission of transforming systems of care to address health disparities and improve health outcomes in our community. The CAB consisted of community members, including families with HRSNs, as well as representatives from the hospital and other CBOs, including the United Way. Collaborations with the United Way grew out of the relationships established through the CAB.The CBPR framework encourages co-designing interventions with the community that consider both hospital and community capacity prior to implementation. Our local co-designed intervention is illustrated in Figure 1. Inpatient nurses screened admitted patients for food, housing, transportation, and utilities insecurity.7 Inpatient social workers (SWs) provided closed-loop referrals to the United Way (our community partner) through a web platform called “Neighborhood Resource.” (A closed-loop referral is when the name and contact information of a patient is provided to a CBO and the CBO confirms that services have been received and that the patient’s social needs are met and documented.8) Hospital partners called patients 72 hours after hospital discharge to ensure they had been contacted by the United Way. If they had not been contacted, hospital partners placed a closed-loop referral to the United Way through “Neighborhood Resource.” The United Way conducted screening for additional HRSNs and then referred to other local CBOs that had the resources to address the needs (Figure 1). The United Way called patients weekly to provide referrals to other CBOs that could provide social services. Hospital partners called families at 30 days after hospital discharge to ascertain whether the families had received tangible aid and get feedback from the families on the intervention.The capacity of both the community partner and the hospital was considered. For instance, we thought about having the inpatient SW call the community partner to provide warm handoff but neither had capacity.Based on the CBPR framework, a community-driven mental model emphasizes that hospital partners should defer to community expertise and pivot their research design to address the concerns of the community.3 In one case, we did defer to CAB expertise about privacy concerns and changed the research design to collect aggregate monthly referral data as opposed to patient-specific referral data. In another case, we did not defer to community expertise when pivoting our research design may have resulted in collecting data that were more meaningful to the community: Hospital partners focused on determining whether receiving resources within 30 days of discharge would reduce the 30-day hospital readmission rate, a commonly used hospital metric. However, community partners cautioned that housing needs, particularly, would take longer than 30 days and suggested asking if families received resources 90 days after discharge instead of 30 days. Calling families at 90 days might have helped us understand the length of time to receive resources in our community, a more meaningful community metric (as opposed to whether receipt of resources within 30 days decreased 30-day readmissions, a hospital-driven metric).The CBPR framework seats pediatric hospitalists as co-learners with community partners.3 For example, in our local context, the community partner learned about the social needs of medically complex children and how social care needs fit into workflows of hospital staff. The hospital also shared findings from the research and patient feedback to the community partner. For example, some families requested a bilingual social navigator or additional help with navigating new social needs that arose after hospital discharge. The community partner was able to provide these additional supports. The hospital partners learned about the availability of community resources for hospitalized children. For example, housing needs in our community increased after COVID-relief programs ended.9 The community partner was able to refer patients to CBOs who had received housing vouchers from our local government.10Within the hospital-community partnership, the pediatrician serves as both a co-learner, deferring to community expertise, and as a child health advocate. A pediatric hospitalist advocates for children by teaching communities about the needs of hospitalized children, thereby building the capacity of community organizations for future work with hospitalized children with HRSNs. In the CBPR framework, one of the outcomes of hospital-community partnerships is increasing the capacity of community partners to do further work as a result of this new knowledge.3 Based on their new knowledge about hospital workflows and the needs of hospitalized children, as well as the outcome data provided by the hospital partner, the community partner was able to successfully apply for grant funding, expanding their capacity to care for the HRSNs of hospitalized children. They were also able to improve their referral program through feedback that our families needed more bilingual support.Forming a hospital-community partnership helped build capacity for both hospital and community partners for future efforts and improved the referral process for the HRSNs of hospitalized children. Building social care referral programs through collaborations with local governments, health systems, and community partners is the work of pediatric hospitalists who are perfectly positioned to do this work as child health advocates and experts in continuous quality improvement. When hospitals and community organizations share a mental model of community partnership that centers community-driven solutions and expertise rather than hospital-directed solutions, community-centered solutions can be sought.1,2,11 In an attempt to shift our profession toward “Hospital B’s” approach to community engagement, this article provides a mental model for pediatricians wanting to move beyond the walls of the hospital in building social care referral programs with community partners.