A Community Resource Navigator Model: Utilizing Student Volunteers to Integrate Health and Social Care in a Community Health Center Setting

Abstract

Introduction: While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work. Methods: We used the Ten Essential Public Health Services Framework to guide program planning of a student “Help Desk” model for a community health center. Planning included a literature review, observation of exemplar programs, development of a CBO directory, and evaluation of the center’s patient population, clinical workflows, and data infrastructure. We piloted the model for two months. After pilot completion, we reviewed patient data to understand the feasibility of the student “Help Desk” model. We utilized planning and pilot execution materials, as well as pilot data, to develop and discuss practical considerations. Results: Design and implementation complemented ongoing social needs screening and referral to CBOs by center case managers. Patients were asked if they would accept telephone follow-up by volunteers two and four weeks after the clinic visit. Of 61 patients screened, 29 patients were referred for follow-up. Ninety percent were reached at least once during the follow-up period, and 48% of patients referred reported connecting to at least one CBO. Only 27% of patients required escalation back to case managers, and no emergency escalation was needed for any patients. Students, faculty advisors, and community health center frontline staff and leadership supported the scale up and continuation of the “Help Desk” model at the community health center. Discussion: Successful implementation required multi-sectoral collaboration, well-defined scope of practice, and data interoperability. Student volunteers are untapped resources to support integrated health and social care.

Workforce Models to Screen for and Address Patients’ Unmet Social Needs in the Clinic Setting: A Scoping Review

“…The remainder reported using observational study designs (eg, pre-post studies, feasibility studies, pilot studies). Fifty-eight studies were conducted with primary care patients, [29][30][31][72][73][74]76,[78][79][80][81][82][83][84][85][86][87][88][89] 4 took place in a specialty clinics, 32,71,75,77 1 took place in urgent care, 27 and 3 took place across multiple settings (eg, primary, specialty, and urgent care). 26,28,90 Majority of studies reported including academic sites (n = 40), 29,[34][35][36][37][38][39][41][42][43][44][47][48][49][50][51][52][53][54][55][56]…”

“…Of the 24 studies that included clinician-administered screening, 1 used medical providers to screen patients, 37 7 used medical residents, [35][36][37][38][39]89,90 1 used a combination of clinical and social care staff (eg, nurse, social worker, medical assistant), 40 and 15 used paid social care staff (eg, case managers, community health workers, navigators) or volunteers. [26][27][28]31,33,[49][50][51]57,60,63,74,78,85,88 In the 8 models using medical providers or residents, they either (1) assisted patients directly through community resource referrals, 38,39 (2) provided community resource referrals with an option to escalate to a social worker or an on-site medical legal partnership, 36,37,47,90 or (3) directly referred patients to social work or the onsite medical legal partnership without providing community resource information themselves. 35,89 In the 15 models that used social care staff or non-physician clinical staff to administer screenings, the same worker who conducted the screening was the same worker to provide initial assistance to patients, 31,36,40,41,44,55,56,58,61,…”

“…35,89 In the 15 models that used social care staff or non-physician clinical staff to administer screenings, the same worker who conducted the screening was the same worker to provide initial assistance to patients, 31,36,40,41,44,55,56,58,61,67 with 2 studies allowing for additional follow-up from separate student volunteers. 78,88 Hybrid models. Three studies described using both selfadministered and clinician-administered screening.…”

“…[26][27][28]34,42,51,52,56,57,63,64,77,[84][85][86]88 In [29][30][31]39,44,46,48,57,60,72,75 or multi-component (n = 17, eg, in-person training and skill-based training). 28,[35][36][37][38]42,47,49,50,61,70,74,86,[88][89][90] Of note, 37 studies did not explicitly report how staff were trained to implement the program. 27,[32][33][34]40,41,43,45,[51]...…”

“…-41,44-48,52,55,58,61,62,64,66,69,70,72,73,75-77,79,83,84,86,87,89,90 21 included the social care workforce, including paid and volunteer staff,[26][27][28]31,33,40,43,[49][50][51]53,57,60,63,72,74,78,80,82,85,88 7 included research staff,29,30,32,65,67,68,71 and 6 did not mention the specific type of worker 34,42,54,56,59,81. For assistance-related activities, 39 studies included the traditional healthcare workforce,29,30,[35][36][37][38][39][40][41][42][43][44][45][46][47][48]…”