Community-based organizations’ perspectives on piloting health and social care integration in North Carolina

Abstract

Background Community-based organizations (CBOs) are key players in health and social care integration initiatives, yet little is known about CBO perspectives and experiences in these pilot programs. Understanding CBO perspectives is vital to identifying best practices for successful medical and social care integration. Methods From February 2021 to March 2021, we conducted surveys with 12 CBOs that participated in the North Carolina COVID-19 Social Support Program, a pre-pilot for North Carolina’s Medicaid Sect. 1115 demonstration waiver program that addresses social drivers of health. Results CBO participants preferred communication strategies that involved direct communication and felt clear communication was vital to the program’s success. Participants expressed varied experiences regarding their ability to handle a changing volume of referrals. Participants identified their organizations’ strengths as: strong organizational operations, past experiences with and understanding of the community, and coordination across organizations. Participants identified challenges as: difficulty communicating with clients, coping with capacity demands for scaling services, and lack of clear processes from external organizations. Almost all CBO participants expressed enthusiasm for participating in similar social care transformation programs in the future. Conclusions CBO participants in our study had broadly positive experiences in the pilot program and almost all would participate in a similar program in the future. Participants provided perspectives that can inform health and social care integration initiatives, including strengths and challenges in such programs. To build and sustain health and social care integration programs, it is important to: (1) support CBOs through regular, direct communication that builds trust and power-sharing between CBO and health care entities; (2) leverage CBO community expertise; and (3) pursue an individualized assessment of CBO capacity and identify CBO capacity-building strategies that ensure program success and sustainability.

Thoughtful Investing in Social Care Management

“…Research on growing partnerships between CBOs and health care organizations have highlighted the process of increased referrals from health care to CBOs but have found overall poor and disorganized communication from health care staff to the partner CBOs. As health care organizations develop electronic referral practices to refer their patient CBOs, CBOs have reported difficulty managing the workflow, giving feedback, or otherwise engaging with the referring health care organization to provide patient-centered care (Agonafer et al, 2021; Nohria et al, 2023; Taylor & Byhoff, 2021). CBOs describe impersonal referral processes and difficulty identifying a point person when issues arise.…”

“…Building billable care management has proved onerous to CBOs. CBOs, compared to health care organizations, have limited technology infrastructure and often find they need to invest significant resources into a data management system to track referrals and billable hours spent by CBO staff engaging in health care–based referrals (Agonafer et al, 2021; Byhoff & Taylor, 2019; Nohria et al, 2023). With the increased demands on the CBO for both data and services, investing in additional care management comes at a significant opportunity cost.…”

“…CBOs describe impersonal referral processes and difficulty identifying a point person when issues arise. In North Carolina, direct communication, particularly between the SW or CHW at the health care system and staff at CBO partners, was highlighted as a strength of social care partnerships (Nohria et al, 2023). A dedicated health care–based social care work force can facilitate communication between the health care organizations who are referring patients out and expect ongoing reporting and communication once patients are referred.…”

Measures of Referral vs Receipt of Social Services Among Patients With Health-Related Social Needs

“…Unmet health-related social needs (HRSNs) are associated with adverse patient health outcomes, contributing to health disparities . On January 1, 2024, the Centers for Medicare & Medicaid Services required hospitals to screen patients for 5 HRSN domains: food, transportation, housing, violence, and utilities.…”

“…Unmet health-related social needs (HRSNs) are associated with adverse patient health outcomes, contributing to health disparities. 1 , 2 , 3 , 4 , 5 , 6 On January 1, 2024, the Centers for Medicare & Medicaid Services required hospitals to screen patients for 5 HRSN domains: food, transportation, housing, violence, and utilities. An expected consequence was finding more patients with HRSNs, necessitating a process to ensure that they were connected to resources, which is often complicated with multiple steps and points of failure.…”