Ralston James D, Gleason Kathy S, Bayliss Elizabeth A, Estacio Karen, Healy Luesa, Holden Erika, McCloskey Jodi, Peterson Ilana, Shulman Lisa, Taylor-McPhail Tobie, Uratsu Connie S, Grant Richard W
Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, 1730 Minor Avenue, Suite 1360, Seattle, WA, 98101-1466, USA.
Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
J Gen Intern Med. 2025 Jun 25. doi: 10.1007/s11606-025-09650-z.
Unmet social needs are common among individuals with multiple chronic health conditions (MCC).
To evaluate the acceptability of proactive outreach to assess and follow up on social health needs among patients with MCC.
Qualitative study using semi-structured interviews.
We interviewed 25 patients with 2 or more chronic health conditions in three integrated care settings in Washington, Colorado, and California that experienced proactive outreach offering assessment and follow-up for social health risks. All patients had a higher likelihood of social health risks based on a predictive model using health plan and electronic health record data. Patients received initial outreach from clinical pharmacists at the Northern California site, licensed practical nurses in primary care at the Washington site, and Community Specialists at the Colorado site.
Transcripts were analyzed using a mixed deductive and inductive thematic approach informed by the Theoretical Framework of Acceptability.
Mean age across the groups was 66 years. We identified five themes common across all three healthcare sites. Participants appreciated the outreach, stating they felt understood and cared for by their providers; recognized how their social needs were intertwined with their physical and mental health; and found that uncomfortable social health conversations were easier with known healthcare providers. Assessment of social health needs and referral to community resources provided some participants with hope that their needs would be met, while others felt discouraged by prior experience. Following referral to community resources, participants had uneven experiences receiving resources to address their needs.
Our results suggest proactive outreach by healthcare team members to assess and address social health needs is valued by patients with MCC despite challenges with accessing some social health resources. Future work is needed to support access to community resources and evaluate the outcomes of outreach to those with MCC who have social needs.
未满足的社会需求在患有多种慢性健康状况（MCC）的个体中很常见。
评估主动 outreach 以评估和跟进患有MCC的患者的社会健康需求的可接受性。
使用半结构化访谈的定性研究。
我们在华盛顿、科罗拉多和加利福尼亚的三个综合护理机构中采访了25名患有两种或更多慢性健康状况的患者，这些机构经历了主动 outreach，提供对社会健康风险的评估和跟进。根据使用健康计划和电子健康记录数据的预测模型，所有患者都有更高的社会健康风险可能性。患者在北加利福尼亚站点接受临床药剂师的初次 outreach，在华盛顿站点接受初级护理中的执业护士的 outreach，在科罗拉多站点接受社区专家的 outreach。
使用由可接受性理论框架指导的混合演绎和归纳主题方法对转录本进行分析。
各组的平均年龄为66岁。我们确定了所有三个医疗保健站点共有的五个主题。参与者对outreach表示赞赏，称他们感到被提供者理解和关心；认识到他们的社会需求如何与他们的身心健康相互交织；并发现与熟悉的医疗保健提供者进行不舒服的社会健康对话更容易。对社会健康需求的评估和转介到社区资源让一些参与者有希望他们的需求会得到满足，而另一些人则因先前的经历而感到气馁。在转介到社区资源后，参与者在获得满足其需求的资源方面经历参差不齐。
我们的结果表明，尽管在获取一些社会健康资源方面存在挑战，但医疗团队成员主动outreach以评估和解决社会健康需求受到患有MCC的患者的重视。未来需要开展工作以支持获取社区资源，并评估对有社会需求的患有MCC的患者进行outreach的结果。
