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Defining the Social Needs Service Cascade: Evidence From A Multistakeholder Qualitative Study.

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Understanding the social needs service cascade is crucial for integrating health and social care. This study identifies key steps from screening to resolution, improving patient support.

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Area of Science:

  • Health Services Research
  • Social Determinants of Health
  • Health Equity

Background:

  • Healthcare systems increasingly screen for social needs, creating a "social needs service cascade" between health and community organizations.
  • This multi-step process, involving patient referrals for unmet social needs, is not well understood beyond initial screening and referral.
  • Integrating health and social care delivery is essential for addressing complex patient needs.

Purpose of the Study:

  • To explore and understand the "social needs service cascade" in detail.
  • To identify critical steps and challenges within the social needs service cascade.
  • To inform future research and policy for better health and social care integration.

Main Methods:

  • Qualitative study involving interviews with clinicians (n=38), community organization representatives (n=14), and patients with type 2 diabetes and food insecurity (n=39).
  • Thematic analysis of qualitative data to identify key components of the social needs service cascade.
  • Conducted as part of an ongoing clinical trial (ClinicalTrials.gov NCT05472441).

Main Results:

  • Identified key steps in the social needs service cascade: screening, referral, lag time, linkage and engagement experience, and resolution.
  • Highlighted the complexities and experiences of patients and providers within this multi-step care process.
  • Revealed areas for improvement in the transition from healthcare screening to community-based social support.

Conclusions:

  • The social needs service cascade involves distinct, critical stages that require further investigation.
  • Findings provide insights for optimizing the integration of health and social care services.
  • Recommendations can guide future policy and interventions to improve patient outcomes by addressing social determinants of health.