Background

Primary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process.

Objective

To characterize referrals to community-based organizations by primary care practices.

Design

Qualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.

Participants

Administrators at 50 diverse US healthcare organizations with efforts to address patients' social risks.

Main measures

Approaches used in primary care to implement social needs referral to community-based organizations.

Results

Interviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.

Conclusion and relevance

Referrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.

Health care organizations increasingly recognize the impact of social needs on health outcomes. As organizations develop and scale efforts to address social needs, little is known about the optimal role for clinicians in providing social care. In this study, the authors aimed to understand how health care organizations involve clinicians in formal social care efforts. In 2019, the authors conducted 33 semi-structured interviews with administrators at 29 health care organizations. Interviews focused on the development and implementation of formal social care programs within the health care organization and the role of clinicians within those programs. A few administrators described formal roles for primary care clinicians in organizational efforts to deliver social care. Administrators frequently described programs that were deliberately structured to shield clinicians (eg, clinicians were not expected to review social risk screening results or be involved in addressing social needs). The authors identified 4 ways that administrators felt clinicians could meaningfully engage in social care programs: (1) discuss social risks to strengthen relationships with patients; (2) adjust clinical care follow-up plans based on social risks; (3) modify prescriptions based on social risks; and (4) refer patients to other care team members who can directly assist with social risks. Administrators were hesitant to increase primary care clinicians' responsibilities by tasking them with social care activities. Defining appropriate and scalable roles for clinicians along with adequate support from other care team members may increase the effectiveness of social care programs.

Purpose

Clinicians and policy makers are exploring the role of primary care in improving patients' social conditions, yet little research examines strategies used in clinical settings to assist patients with social needs.

Methods

Study used semistructured interviews with leaders and frontline staff at 29 diverse health care organizations with active programs used to address patients' social needs. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity, and use of referrals to community-based organizations (CBOs).

Results

Organizations used case management programs to assist patients with social needs through referrals to CBOs and regular follow-up with patients. About one-half incorporated care for social needs into established case management programs and the remaining described standalone programs developed specifically to address social needs independent of clinical needs. Referrals were the foundation for assistance and included preprinted resource lists, patient-tailored lists, and warm handoffs to the CBOs. While all organizations referred patients to CBOs, some also provided more intense services such as assistance completing patients' applications for services or conducting home visits. Organizations described 4 operational challenges in addressing patients' social needs: (1) effectively engaging CBOs; (2) obtaining buy-in from clinical staff; (3) considering patients' perspectives; and (4) ensuring program sustainability.

Conclusion

As the US health care sector faces pressure to improve quality while managing costs, many health care organizations will likely develop or rely on case management approaches to address patients' social conditions. Health care organizations may require support to address the key operational challenges.Visual abstract.

Purpose

The COVID-19 pandemic resulted in unprecedented adoption and implementation of virtual primary care services, and little is known about whether and how virtual care services will be provided after the pandemic ends. We aim to identify how administrators at health care organizations perceive the future of virtual primary care services.

Methods

In March-April of 2021, we conducted semistructured qualitative phone interviews with administrators at 17 health care organizations that ranged from multi-state nonfederal delivery systems to single-site primary care practices. Organizations differed in size, structure, ownership, and geography. We explore how health care administrators anticipate their organization will offer virtual primary care services after the COVID-19 pandemic subsides.

Results

All interviewed administrators expected virtual primary care services to persist after the pandemic. We categorize expected impact of future virtual services as limited (n = 4); targeted to a narrow set of clinical encounters (n = 5); and a major shift in primary care delivery (n = 8). The underlying motivation expressed by administrators for providing virtual care services was to remain financially stable and competitive. This motivation can be seen in the 3 main goals described for their anticipated use of virtual services: (1) optimizing medical services; (2) enhancing the patient experience; and (3) increasing loyalty among patients.

Conclusions

Health care organizations are considering how virtual primary care services can be used to improve patient outcomes, access to care, and convenience of care. To implement and sustain virtual primary care services, health care organizations will need long-term support from regulators and payers.

Background

The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services.

Objective

To understand how Medicare ACOs provide preventive care services to their attributed patients.

Design

Mixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs.

Participants

ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.

Main measures

Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services.

Key results

Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients' preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets.

Conclusions

ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.