Outreach Assessment for Social Health Needs in Patients with Multiple Chronic Conditions: Qualitative Study of...

Unmet social needs are common among individuals with multiple chronic health conditions (MCC).

To evaluate the acceptability of proactive outreach to assess and follow up on social health needs among patients with MCC.

Qualitative study using semi-structured interviews.

We interviewed 25 patients with 2 or more chronic health conditions in three integrated care settings in Washington, Colorado, and California that experienced proactive outreach offering assessment and follow-up for social health risks. All patients had a higher likelihood of social health risks based on a predictive model using health plan and electronic health record data. Patients received initial outreach from clinical pharmacists at the Northern California site, licensed practical nurses in primary care at the Washington site, and Community Specialists at the Colorado site.

Transcripts were analyzed using a mixed deductive and inductive thematic approach informed by the Theoretical Framework of Acceptability.

Mean age across the groups was 66 years. We identified five themes common across all three healthcare sites. Participants appreciated the outreach, stating they felt understood and cared for by their providers; recognized how their social needs were intertwined with their physical and mental health; and found that uncomfortable social health conversations were easier with known healthcare providers. Assessment of social health needs and referral to community resources provided some participants with hope that their needs would be met, while others felt discouraged by prior experience. Following referral to community resources, participants had uneven experiences receiving resources to address their needs.

Our results suggest proactive outreach by healthcare team members to assess and address social health needs is valued by patients with MCC despite challenges with accessing some social health resources. Future work is needed to support access to community resources and evaluate the outcomes of outreach to those with MCC who have social needs.