Structural readiness of CBOs to address health-related social needs in chronic disease management programs

Addressing health-related social needs (HRSN) such as food insecurity, housing instability, and transportation barriers has become increasingly recognized as essential to improving chronic disease outcomes. Community-based organizations (CBOs) are uniquely positioned to assess and address HRSN due to their embeddedness within local communities. CBOs that provide chronic disease self-management programs may have distinct capacities to integrate HRSN support, tailor interventions to community contexts, and build trusting relationships that enhance client engagement and sustain behavior change. However, limited research has examined the structural and organizational capacities required for CBOs to systematically integrate HRSN-related services in chronic disease management contexts.

An environmental scan using a structured, purposive search was conducted to identify literature relevant to CBOs, HRSN, and chronic disease across PubMed, Scopus, and targeted Google searches. Of 224 sources identified, 20 were included for analysis. Data were organized using a structured matrix and analyzed through thematic synthesis using a modified Strengths, Weaknesses, Opportunities, and Threats (SWOT) framework to guide coding and distinguish internal and external factors. Findings were subsequently interpreted using the Consolidated Framework for Implementation Research to contextualize results across implementation domains.

CBOs demonstrated variation in capacity to assess and address HRSN. Facilitators included patient navigation services, community-aligned missions, and cross-sector partnerships. Barriers included limited data infrastructure, inconsistent referral processes, and resource constraints. A capacity continuum emerged, illustrating how internal organizational factors and external conditions interact to shape reach and effectiveness. Two key insights included a partnership paradox, in which capacity is often required to form partnerships, and a bidirectional relationship between data capacity and external engagement.

Findings indicate that CBO capacity is shaped by multilevel factors, including organizational systems, policy and funding environments, and the availability of community resources. Strengthening this capacity will require sustained investment in data infrastructure, workforce development, and community-based services, as well as alignment between partnership expectations and organizational readiness. These findings also underscore the importance of addressing structural resource constraints alongside coordination efforts and provide implementation-informed insights to guide future research, policy, and program design aimed at strengthening CBO capacity to deliver HRSN-related services within chronic disease self-management programs.