Coordinating Multisector Efforts to Address Social Needs in a Rural Midwestern Primary Care Setting

Area of Science:

• Health Services Research
• Social Determinants of Health
• Primary Care Interventions

Background:

• Screening for social drivers of health (SDoH) is increasing in primary care.
• Effective intervention models are needed to address identified SDoH needs.
• A Health Equity Coordinator (HEC) model was implemented to facilitate clinic-community partnerships.

Purpose of the Study:

• To assess a Health Equity Coordinator (HEC) model's process outcomes.
• To evaluate the resolution of social drivers of health (SDoH) needs.
• To examine changes in healthcare utilization associated with the HEC model.

Main Methods:

• Cohort study design comparing an intervention clinic with two comparator clinics (March 2022 - December 2023).
• Assessed process outcomes descriptively.
• Used multivariable regression to analyze SDoH need resolution and healthcare utilization.

Main Results:

• The HEC engaged 348 patients and held 748 meetings with community organizations.
• Observed decreases in SDoH needs and appointment no-shows/cancellations in the intervention group.
• No significant differences in SDoH resolution or healthcare utilization compared to control groups.

Conclusions:

• The HEC model shows potential for patient referrals and stakeholder engagement in primary care.
• The model effectively facilitated multi-stakeholder coordination.
• Longer-term follow-up is recommended to determine sustained effects on SDoH and healthcare utilization.