A Missed Opportunity? How Health Care Organizations Engage Primary Care Clinicians in Formal Social Care Efforts

Popul Health Manag. 2022 Aug;25(4):509-516. doi: 10.1089/pop.2021.0306. Epub 2022 Feb 21.


Health care organizations increasingly recognize the impact of social needs on health outcomes. As organizations develop and scale efforts to address social needs, little is known about the optimal role for clinicians in providing social care. In this study, the authors aimed to understand how health care organizations involve clinicians in formal social care efforts. In 2019, the authors conducted 33 semi-structured interviews with administrators at 29 health care organizations. Interviews focused on the development and implementation of formal social care programs within the health care organization and the role of clinicians within those programs. A few administrators described formal roles for primary care clinicians in organizational efforts to deliver social care. Administrators frequently described programs that were deliberately structured to shield clinicians (eg, clinicians were not expected to review social risk screening results or be involved in addressing social needs). The authors identified 4 ways that administrators felt clinicians could meaningfully engage in social care programs: (1) discuss social risks to strengthen relationships with patients; (2) adjust clinical care follow-up plans based on social risks; (3) modify prescriptions based on social risks; and (4) refer patients to other care team members who can directly assist with social risks. Administrators were hesitant to increase primary care clinicians' responsibilities by tasking them with social care activities. Defining appropriate and scalable roles for clinicians along with adequate support from other care team members may increase the effectiveness of social care programs.

Keywords: clinicians; primary care; social care; social determinants of health; workforce.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Delivery of Health Care
  • Humans
  • Primary Health Care*
  • Social Support*