Extending the Care Continuum: Spotlight on Social Needs Integration

When we ran our SN201 Workshop Alumni Survey earlier this year, I wasn’t surprised to learn that 96% of folks who participated in our Workshop are currently screening and referring patients to essential needs or planning to do so within a year. What did surprise me was the number of unique and creative ways each team has adapted their social needs strategies to meet the evolving needs of their patient populations, funding models and organizational structures.

At The Dimock Center, a Boston-based community health center and long-time Health Leads partner, adaptiveness and flexibility is the heart and soul of their social needs efforts. Their aim is to establish primary care as integrated biopsychosocial care – a place where people can address their medical, social and behavioral health needs all under one roof. What began as a volunteer-driven pilot in the pediatrics clinic in 2010 now extends to Dimock’s adult medicine and the OBGYN clinics. The team still includes volunteers, but now also includes seven community health workers who play a key role across practices.

Dr. Michael Tang, Clinical Director of Behavioral Health Integration at the Dimock Center, has been a driving force in the evolution, scalability and sustainability of social needs initiatives at Dimock. The big takeaway according to Dr. Tang?  “It’s about creating a collaborative, multi-disciplinary culture of warm hand-offs, accountability and visibility.”

What does this mean at The Dimock Center?

  • Centralizing workspaces, technologies and reporting structures. Every member of the behavioral and social health teams reports to the same director and share the same office space – promoting interdisciplinary collaboration and reducing competition. Every team member has access to the Health Leads Reach® resource database and case management system.
  • Adapting scope of services, and workforces, across clinics. While each team uses the same the same technology, workflows vary across the four clinics, using five different workforce models and scopes of service that are adapted to staffing capacity and patient needs. In the adult medicine clinic, two community health worker screen only for the most prevalent essential needs and connect patients to the most ready-available resources. In the pediatric clinic, with three full-time staff and up to 12 student volunteers, all patients are universally screened for a broader scope of needs and can receive on-going case management.
  • Recognizing the unique contributions of each staff member. At Dimock, the integration of social health teams in the behavioral health program creates space for social workers to focus on providing therapy services, while social health staff navigate patients to essential needs resources. Hiring community health workers, who share the cultural, linguistic and often social experience of patients, created an opportunity for longer-term case management and additional support as needed.

Are you starting or refining a social needs intervention? Read more about The Dimock Center’s approach in our case study!