Sandhu Sahil, Xu Jacqueline, Blanchard Lillian, Eisenson Howard, Crowder Carolyn, Munoz Veronica Sotelo, Drake Connor, Bettger Janet Prvu
Trinity College of Arts & Sciences, Duke University, Durham, NC, USA.
Lincoln Community Health Center, NC, USA.
Int J Integr Care. 2021 Feb 5;21(1):2. doi: 10.5334/ijic.5501.
While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work.
We used the Ten Essential Public Health Services Framework to guide program planning of a student "Help Desk" model for a community health center. Planning included a literature review, observation of exemplar programs, development of a CBO directory, and evaluation of the center's patient population, clinical workflows, and data infrastructure. We piloted the model for two months. After pilot completion, we reviewed patient data to understand the feasibility of the student "Help Desk" model. We utilized planning and pilot execution materials, as well as pilot data, to develop and discuss practical considerations.
Design and implementation complemented ongoing social needs screening and referral to CBOs by center case managers. Patients were asked if they would accept telephone follow-up by volunteers two and four weeks after the clinic visit. Of 61 patients screened, 29 patients were referred for follow-up. Ninety percent were reached at least once during the follow-up period, and 48% of patients referred reported connecting to at least one CBO. Only 27% of patients required escalation back to case managers, and no emergency escalation was needed for any patients. Students, faculty advisors, and community health center frontline staff and leadership supported the scale up and continuation of the "Help Desk" model at the community health center.
Successful implementation required multi-sectoral collaboration, well-defined scope of practice, and data interoperability. Student volunteers are untapped resources to support integrated health and social care.
未满足的社会需求是健康结果的主要驱动因素，但大多数卫生系统并未与社会护理部门充分整合以应对这些需求。在本案例研究中，我们描述了一个利用学生志愿者社区资源导航员帮助患者与社区组织（CBO）建立联系的模型的开发与实施。然后，我们详细介绍了初步实施成果以及未来工作的实际考量。
我们使用《十项基本公共卫生服务框架》来指导为社区卫生中心制定学生“服务台”模型的项目规划。规划包括文献综述、对典范项目的观察、编制CBO名录，以及评估中心的患者群体、临床工作流程和数据基础设施。我们对该模型进行了为期两个月的试点。试点结束后，我们审查患者数据以了解学生“服务台”模型的可行性。我们利用规划和试点执行材料以及试点数据来制定和讨论实际考量。
该模型的设计与实施补充了中心个案管理人员正在进行的社会需求筛查及向CBO的转诊工作。在诊所就诊后的两周和四周，会询问患者是否接受志愿者的电话随访。在筛查的61名患者中，有29名患者被转介进行随访。在随访期间，90%的患者至少被联系过一次，48%被转介的患者报告与至少一个CBO建立了联系。只有27%的患者需要转回给个案管理人员，且没有任何患者需要紧急转诊。学生、教师顾问、社区卫生中心的一线工作人员和领导层都支持在社区卫生中心扩大和延续“服务台”模型。
成功实施需要多部门协作、明确的实践范围和数据互操作性。学生志愿者是支持综合健康和社会护理的未开发资源。
