"More than just giving them a piece of paper": Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

J Gen Intern Med. 2022 Dec;37(16):4160-4167. doi: 10.1007/s11606-022-07531-3. Epub 2022 Apr 14.


Background: Primary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process.

Objective: To characterize referrals to community-based organizations by primary care practices.

Design: Qualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.

Participants: Administrators at 50 diverse US healthcare organizations with efforts to address patients' social risks.

Main measures: Approaches used in primary care to implement social needs referral to community-based organizations.

Results: Interviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.

Conclusion and relevance: Referrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.

Keywords: clinicians; primary care; referrals; social determinants of health; social risks.

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
  • Qualitative Research
  • Referral and Consultation*