Organizational Approaches to Social Needs and Roles of Patients
| Social Care Approach | Organizational Approach and Example Quotes | |
|---|---|---|
| Program structure for treating social needs | Treated as an acute condition “If you have a Medicaid patient who has transportation needs to health care visits. That’s easy to solve. You can solve that in one phone call.” (System; organization 8; executive leadership) “So that to me is short-term case management. That’s one, maybe two visits. It’s problem-solving, and then you move it through.” (System; organization 21; executive leadership) | Treated as a chronic condition “I’m looking at some of the patients that I’m working with now and it may take several home visits or several calls just to complete one task. So they will be staying with you for a while. It’s hard to say, but in general a few months maybe.” (System; organization 12; case management staff) |
| Program design of staff and patient collaboration for development of social care plans | Health care staff drove the care plan “I tell them I will make a care plan for your needs.” (Practice; organization 16; case management staff) “She wanted her Medicaid [renewal]. But in looking over her papers, we noticed that […] she hadn’t paid her taxes in I don’t know how many years […]. We said, “You know what? This is the most important thing. This is what’s going on right now.” (Practice; organization 15; case management staff) | Patients drove the care plan “The patient may identify a different set of goals than what you would have guessed looking at that screener. We spend a lot of time working on motivational interviewing and really person-centered goal setting.” (System; organization 8; executive leadership) |
| Extent of health care organizations encouraging staff to partner with patients to address social needs | Patients were primarily responsible “It’s essentially connecting them and giving them the information and then it’s up to the patient to contact those organizations and move the steps forward.” (Practice; organization 1; program management) “So, we try to empower our patients, and so if it’s a patient who either can certainly do things on their own, they just don’t know how to access resources, they’ll teach them or talk to them about what’s available. They’ll sit with them to make phone calls if they need to.” (System; organization 12; executive leadership) | Staff and patients were a team “Years ago he had lost his birth certificate. He was living in his truck down by the river. […] Our case manager worked with him through an entire process […] Once that [identification] got here then she assisted him to complete the housing applications that he needed to complete. Once that was done he actually got a house, or an apartment. Then she continued to follow up with him for I think it was six months. And he’s doing fantastic.” (Practice; organization 18; case management staff) |