Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System

Authors: Marc Shi, Kevin Fiori, Ryung S. Kim,Qi Gao, Galina Umanski, Iby Thomas, Andrew Telzak, and Earle Chambers

This study sought to identify predictors of successful linkage with a CHW among patients with social needs seen in an outpatient setting. A cross-sectional analysis of social needs was conducted in an urban health system in Bronx, New York, USA between April 2018 and December 2019. Social needs and challenges included: food insecurity, housing quality, housing instability, healthcare costs, healthcare-related transportation, utilities, care for dependents, legal assistance, safety, and getting along with household members. Results demonstrated that among patients with at least 1 social need who requested assistance, 25% had a successful linkage to a CHW, as defined by having a documented record in the CHW database. Positive predictors of CHW linkage included female gender, Spanish language preference compared to English, and having a food-related need. Despite some positive findings, this study highlights a further need for system-level improvements to be made to screening and referral procedures to target at-risk patients and communities and enhance their engagement with the CHW workforce.