Exploring the capacity of community‐based organisations to absorb health system patient referrals for unmet social needs

Abstract

This study examines the perspectives, resources, role and services provided by community‐based organisations (CBOs) in response to the integration of health and social services to address individual unmet social needs, as well as the impact on organisational carrying capacity related to the ability to receive referrals from health system partners. Mixed methods combining qualitative interviews with 24 organisations and Social Network Analysis with 75 organisations were completed in 2018 in two communities (Denton, TX and Sarasota, FL) with robust examples of health and social systems alignment. Findings suggest that while community organisations are embedded in robust cross‐sector networks, the potential increase in referrals from clinical settings is not something they are fully aware of, or prepared for, as evidenced by inadequate funding models, misalignment between capacity and capability, and a lack of coordination on screening and referral activities. Misalignment between clinical and CBO understanding of demand, needs and capacity present a potential risk in building strategies that integrate health and social services to address unmet social need. Failing to build a strong cross‐sector screening and referral infrastructure that considers CBO capacity from the start could undermine the goal of improving population health through the integration of clinical and social care.

Understanding the Development, Evaluation, and Sustainability of Community Health Networks Using Social Network Analysis: A Scoping Review

“…32 Another study of 2 regional attempts to integrate health and social services found that community organizations were in wellconnected cross-sector networks (number of connections), but were not fully prepared for the resultant increases in referrals from the health system due to insufficient funding and lack of referral coordination. 87 Network characteristics also played a role in outcomes. For organizations involved in sharing administrative and client information, stronger linkages correlated with higher perception of network administration and service delivery effectiveness.…”

Moving beyond referrals to strengthen late-life depression care: a qualitative examination of primary care clinic and community-based organization partnerships

“…Community-based organizations (CBOs) may be well-positioned to support primary care clinics in addressing the social factors of depression given their focus on social needs and often high-standing in lower-resourced communities [35,36]. However, previous studies have suggested CBO and clinical partners are often misaligned in their understandings of capacity and demand, leaving CBOs to absorb high volumes of referrals they may not have capacity to address [37]. Thus, we argue crossorganizational partnerships that integrate social care services and establish lines of communication beyond traditional referral models may help to alleviate these de cits and improve care.…”

Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations

“…To do this, community-based and person-focused paradigms of care must be strengthened [ 63 ] and community stakeholders must be considered as co-producers of care [ 64 ] and, ultimately, as co-builders of social policies [ 21 ] for people with complex needs. Decision makers must consider adequate funding [ 60 ] dedicated to community stakeholders participation in individualized service plans [ 65 , 66 ] and their engagement in CMPs. In the same way, the programs need to be supported and pursued in a perspective of ongoing improvement.…”