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Fraze et al.’s recent article “Resource Brokering: Efforts to Assist Patients With Housing, Transportation, and Economic Needs in Primary Care Settings” takes up an important issue for primary care and general health care delivery in looking to understand how providers support patients in accessing social services. We are heartened to see the challenges of addressing social determinants framed as organizational-level rather than individual provider or patient level challenges. The study highlights missed opportunities to broker effective relationships with community based organizations (CBOs) and presents common pitfalls of health care entering the space of social service delivery.
We took special note that one of the operational challenges identified by Fraze et al was that health care organizations were reticent to engage directly with CBOs (Table 4 - Engaging CBOs). Instead of direct, inter-professional relationships, the primary way health care providers and CBOs were joined appears to be through the referral of patients back and forth via case management. This is understandable given the time and financial pressures health care providers are under. Still, it raises the question of whether what we are seeing in Fraze et al.'s findings is really an instance of brokerage - defined by Ronald Burt as increasing diversity of relationships in an otherwise tightly clustered network. This is an open area of inquiry not only for this study but for people engaged in the development of community-clinical linkages writ large.
Fraze et al report that reticence of clinical staff to engage directly with CBOs existed alongside clinical staff feeling ill-equipped to do much in the way of social care delivery themselves (See Table 4, Buy-in among clinical staff). This is a common refrain that we have heard in our own work that misses a key point about how labor comes to be divided. If providers and clinical staff feel that social care remains outside of their purview, this increases the importance of valuing the unique brokerage role of social work staff who can shuttle tasks not well suited to health care to CBOs. It is all but unavoidable that social needs will continue to “show up” in primary care visits for the foreseeable future. Partnership with CBOs should be of primary importance to ensure that the social care is delivered by someone else. The more clinical teams pull back from engagement with social care, the more likely social needs are to continue to roll into their laps.
Although Fraze et al leave the term undefined, delving into Burt’s concept of brokering presents further insights into the ongoing relationship between health care and CBOs. Individuals whose networks extend beyond a tightly clustered network and into new networks - say, to community based organizations - are brokers in a classical sense. Brokers tend to have improved information and vision than the average person in a densely clustered network on account of their access to other networks. For health care personnel engaged in SDOH work, relevant information gleaned through network connections into CBOs might include specifics of what CBOs have previously learned about patients, what kinds of services and supports CBOs can offer and what CBOs would need to improve their quality. This information should allow brokers to develop creative ideas about how to address SDOH challenges that might not be available or obvious to individuals or care teams who are situated in the middle of a densely clustered health care network.
Fraze et al mention that “Relationships between health care organizations and CBOs relied on staff-to-staff interactions.” It’s not immediately clear from the study what kinds of job titles these staff held but it is they who stand to be brokers. Case managers (or community health workers or social workers) traditionally have had roles that require entrepreneurial, inter-professional relationship-building, both with patients and with outside social service providers. That said, case management has come to mean many different things in different organizations. Nevertheless, we see an opportunity for future work to generate novel insights by sampling from those staff who are having direct interactions with CBOs, rather than continuing to focus on managers and leadership. What remains to be seen is whether health care teams will value and harvest the unique information that these brokers would bring to a discussion of SDOH programming. We worry that instead, health care will rush to design and implement programming based on pre-existing assumptions and routines, and scale services in the name of population health management.
The future of organizational analysis of how social determinants are being addressed should be bright. We see opportunities to follow-on the work that Fraze et al. have put forward. A natural next step would be to conduct network analyses to improve our understanding of what roles, or other groupings of people, offer the greatest opportunity for brokerage out of dense health care networks. We would also see value in a follow-up study with people who occupy said brokerage roles in health care and CBO settings, and compare their perspectives to the people in leadership positions in this study. Burt would hypothesize that those in the brokerage roles have considerably more vision (and perhaps even “better” ideas) about how to do this work differently. It would also be very helpful to see additional research teams following Fraze et al.’s footsteps by studying, and describing, how the provision of social supports is organized within health care bureaucracies. This study presents an excellent model for how to do this kind of work but, as always, larger and more diverse samples would help the field to move more quickly to generalizable insights.