Post-Identification Approaches to Addressing Health-Related Social Needs in Primary Care: A Qualitative Study

Background: Social determinants of health play a fundamental role in a patient’s health status. In recent years, health systems across the nation have implemented numerous strategies aimed at identifying and addressing the health-related social needs of the patients they serve. Despite the influx of peer-reviewed research highlighting outcomes of specific health-related social needs interventions, the spectrum of practices utilized by primary care clinics has not been established. Objective: To determine the range of ways primary care clinics address health-related social needs after identification and initial contact with a frontline staff person is completed. Design: We conducted 12 semi-structured, in-person interviews with staff from purposively sampled clinics. If the interview included more than one staff person, all participants were interviewed together. Participants: Twenty-one administrative staff and frontline clinic personnel with experience in 24 separate primary care clinics in the Minneapolis-St. Paul, Minnesota metropolitan area. Approach: Interviews focused on the range of health-related social needs processes utilized by clinics, including staff titles, referral procedures, and barriers to addressing needs. Interview recordings were transcribed and coded using thematic analysis. Key Results: Thematic analysis identified variation in four key areas involving how clinics address patients’ health-related social needs after identification and initial contact by frontline staff: clinic personnel involved in addressing needs, clinic referral processes, “resource” and “success” definitions, and barriers to accessing community-based supports. Conclusions: This study describes the large variation in primary care clinic practices to address health-related social needs after they are identified. The results suggest challenges to standardization and real-world application of previously published studies. Our findings also highlight the opportunity for improved relationships between health systems and community-based agencies.