There is a growing understanding that social health – the non-medical factors like housing, food security and transportation that can prevent people from staying healthy – is key to successful population health management. But health systems often struggle to bridge the gap between identification of social needs and connecting patients to the most relevant and reliable community resources. A collaboration between Boston Children’s Hospital and the Boston Public Health Commission (BPHC) offers a powerful example of a program that made a measurable difference.
Identifying a patient or family suffering from unmet social needs comes with significant challenges for healthcare organizations:
- Lack of available knowledge about the issues
- Discomfort discussing those issues directly
- Confusion about referral processes
No matter the case, a significant gap exists between the number of people who could benefit from referrals to community resources and the number of people who are actually able to seek help. Research from Boston Children’s and BPHC indicated that while many patients strongly desired assistance, clinics screened for social needs at very low rates and provided less than half of the desired referrals.
Boston Children’s and BPHC collaborated to develop a free web-based portal – HelpSteps – which clinicians can use to screen families for health-related social problems and connect them with local organizations. HelpSteps offers a screening questionnaire paired with a referral database that aggregates social services available throughout Boston. Formalizing the process of identifying patients’ needs allowed a much wider group of patients to arrive at the referral stage, and then access everything from descriptions of available services to eligibility information to local public transportation.
During an 18-month period, HelpSteps was incorporated into adolescent primary care visits at Boston Children’s’ Adolescent/Young Adult Clinic. The implementation revealed that 76% of youth screen positive for at least one major social problem and nearly half experienced two or more. From this, HelpSteps helped generate more than 1,500 referrals and nearly half of patients that selected referral services successfully addressed their priority problem. These mirrored the results seen when HelpSteps was then implemented in Boston Children’s’ Primary Care Center, which saw a nearly four-fold increase in participation over its first four years and over 12,000 social services selected annually.
There is no shortage of individuals and families that could benefit from resources that would help them with the non-medical factors directly impacting their health. At the same time, health systems can play a key role in making the best use of local or online community resources. Tools like HelpSteps are critical to connecting patients to the most helpful services and resources. The collaboration between Boston Children’s Hospital and Boston Public Health Commission also demonstrates the potential of public-private partnerships in improving the health of communities. Additional details available from the National Academy of Medicine below.