Brewster Amanda L, Hernandez Elizabeth, Knox Margae, Rubio Karl, Sachdeva Ishika
School of Public Health, University of California, Berkeley, Berkeley, California, USA.
Contra Costa Health, Martinez, California, USA.
Health Serv Res. 2025 May;60 Suppl 3(Suppl 3):e14402. doi: 10.1111/1475-6773.14402. Epub 2024 Nov 18.
To test quantitative process measures characterizing the work of social needs case managers as they assisted patients with diverse health-related needs-spanning both medical and social domains.
The study analyzed secondary data on 7076 patients working with 147 case managers from the CommunityConnect social needs case management program in Contra Costa County, California from 2018 to 2021. The service-designed to be holistic with a focus on social determinants as root causes of health issues-helped patients navigate social services, health care, and mental health care.
We used cross-sectional analyses to quantitatively characterize electronic health records (EHRs) derived measures of case management intensity (goal updates), duration (days goal was open), and outcomes for 19 different categories of health and social goals. Mixed-effects regression models were used to examine how work process measures varied according to goal categories. Models nested goals within patients within case managers and adjusted for patient-level covariates.
The most common goals were dental care (53%), food (40%), and housing (39%). In adjusted analyses, housing goals had significantly more case manager updates than any other type of goal with a marginal mean of 14.0 updates (95% CI: 13.4-14.7), were worked on for significantly longer (marginal mean of 417 days, 95% CI: 360-474) than any goal except dental care, and were least likely to be resolved. Utilities, insurance, and medication coordination goals were most likely to be resolved.
Case managers and patients repeatedly worked on goals over many months. Meeting housing needs and accessing dental care were issues that were not easily resolved and required extensive follow-up. One-time referral interventions may need follow-up systems to meaningfully support social and health needs.
测试定量过程指标，以描述社会需求个案管理员在协助有各种与健康相关需求（涵盖医疗和社会领域）的患者时的工作情况。
该研究分析了2018年至2021年加利福尼亚州康特拉科斯塔县社区连接社会需求个案管理项目中147名个案管理员所服务的7076名患者的二手数据。该服务旨在全面综合，将社会决定因素视为健康问题的根本原因，帮助患者获得社会服务、医疗保健和心理健康护理。
我们采用横断面分析来定量描述电子健康记录（EHR）得出的个案管理强度（目标更新）、持续时间（目标开放天数）以及19种不同类别的健康和社会目标的结果。混合效应回归模型用于检验工作过程指标如何因目标类别而异。模型将目标嵌套在个案管理员中的患者之内，并对患者层面的协变量进行了调整。
最常见的目标是牙科护理（53%）、食品（40%）和住房（39%）。在调整分析中，住房目标的个案管理员更新显著多于任何其他类型的目标，边际均值为14.0次更新（95%置信区间：13.4 - 14.7），处理时间显著长于除牙科护理外的任何目标（边际均值为417天，95%置信区间：360 - 474），且最不可能得到解决。水电费、保险和药物协调目标最有可能得到解决。
个案管理员和患者在多个月里反复处理目标。满足住房需求和获得牙科护理是不易解决且需要大量后续跟进的问题。一次性转介干预可能需要后续跟进系统，以切实支持社会和健康需求。
