Community Based Organization Stakeholder Perspectives on Partnership with a Pediatric Health System for Addressing Patients' Health-Related Social Needs

Pediatric health systems are implementing social determinants of health screening and referral programs to assist patients and their families, meet regulatory requirements, and to participate in value-based arrangements, and the success of these programs relies on meaningful relationships with community-based organizations. Community-based organization stakeholders provided their perspectives on the current state of screening and referrals for health-related social needs including challenges and facilitators for sustainable referral practices, and they provided recommendations on strengthening partnerships between the health system and community-based organizations. Qualitative data was collected via semi-structured interviews conducted on Microsoft Teams; ten stakeholders who worked for or with community-based organizations to assist patients’ caregivers who screened positive for unmet health-related social needs completed interviews. Stakeholders described their current state of receiving referrals, the needs of their clients, and challenges they encountered matching resources to specific domains. Food resources were most available, while affordable housing was largely unattainable. They noted threats to sustainability with regards to funding sources and they highlighted relationships with their community members, between agencies, and with the health system as facilitators to service delivery. They shared the outcomes that they track within their organizations, which were disparate, which adds to the complexity of determining impacts of such programming. They provided recommendations to the healthcare system which included improving closed-loop communication pathways, increasing communication, and pooling of outcomes data to demonstrate the community need and potentially return on investment of such programs. Pediatric health systems can act across the spectrum of population health activities by using screening to understand the needs of their community, addressing health-related social needs of individual patients’ families through partnerships with community-based organizations, and developing shared agendas with service-based groups to advocate for value-based care models to fund interventions that address social determinants of health.