Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program

Clin Pediatr (Phila). 2020 Jun;59(6):547-556. doi: 10.1177/0009922820908589. Epub 2020 Mar 5.


Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.

Keywords: community health workers; implementation science; primary care; social determinants of health; social needs.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Community Health Workers*
  • Humans
  • Needs Assessment / statistics & numerical data*
  • New York City
  • Poverty / statistics & numerical data
  • Primary Health Care / methods*
  • Program Evaluation*
  • Referral and Consultation / statistics & numerical data
  • Social Determinants of Health / statistics & numerical data*