Multisector Health Equity Coordination in a Midwestern Primary Care Practice, 2022-2023

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives.

Objective: To assess the function and impact of a new role, a Health Equity Coordinator, on the reach of the social needs screening and referral program.

Study Design and Analysis: This is a descriptive analysis of the implementation of the social needs screening and referral program.

Setting or Dataset: A tracking document used to manage the social needs screening and referral system.

Population Studied: Patients at a large primary care practice in the Mayo Clinic Health System located in Mankato, MN.

Intervention/Instrument: A midwestern primary care practice implemented a social needs screening and referral program centered on a Health Equity Coordinator (HEC), a new role created to manage the pathway from screening to connection to community resources.

Outcome Measures: Program reach, descriptive information on the patient population, and HEC effort spent on cases, community engagement, administrative tasks, and presentations.

Results: Between March 2022 and December 2023, the program served 512 patients with a total of 355 contact hours required to connect with patients and refer to appropriate resources as requested. Contact hours included a mix of in-person visits and phone calls. Adult patients ranged in age from 18 to 92; a small number of patients under the age of 18 (n=18) required engagement with guardians. During this same period, the HEC engaged in 826 meetings with local CBOs requiring more than 1,400 total contact hours. In addition to this work “on the ground,” the Health Equity Coordinator also made over 20 presentations to various Mayo Clinic committees, CBOs, and other community stakeholders to disseminate progress and establish support for the program. The role required administrative work to establish and maintain functionality across systems, including Epic, Findhelp, and various committees and workgroups totaling over 1,200 hours.

Conclusions: During the first year, the HEC developed the infrastructure for the clinic to engage with patients, providers, and CBOs to build capacity to meet the needs of patients. Although the HEC role was created to connect patients to resources, most of the work required to do this effectively was internal-facing and in partnership with CBOs rather than direct patient contact.