Addressing Health-Related Social Needs in Clinical Practice: Scaling and Sustaining Local Interventions Through Statewide Learning and Action

Overview: 

Health-related social needs (HRSNs), such as housing, transportation, food, and toxic stress, are key factors that influence a person’s health outcomes. Millions come into contact with the medical system each year, in primary care, the emergency department, or specialty clinics, providing an opportunity for intervention not only for patients’ medical needs, but also their HRSNs. Across Duke Health, North Carolina, and the country, efforts are underway to address HRSNs in clinical settings. However, these efforts are largely uncoordinated and are subject to financial sustainability challenges. Opportunities exist to improve these interventions through streamlined clinical integration, multi-stakeholder collaboration, and sustained and scalable investments. Additionally, technological innovation in patient engagement provides an opportunity for providers and patients to connect health and social care. 

Duke-Margolis, in close collaboration with Duke Health (inclusive of Duke University Health System and School of Medicine) is beginning a new research, implementation, and policy project focused on integrating HRSN interventions into the clinical setting. Using food insecurity as an initial use case, we aim to sustainably advance whole-person, evidence-based care. One workstream will be focused on the implementation of HRSN interventions in clinical settings, and a concurrent workstream will be focused on patient engagement innovation design. This workstream will identify opportunities for innovation in technology and digital health for patient engagement with HRSN interventions. Over the next 2.5 years, the project team will carry out three phases of this project. 

Funding: 

Funding for this project is provided by The Duke Endowment.