While healthcare systems have improved how they approach the social needs of their patients by referring them to resources, referrals alone simply aren’t enough. For it to have a chance of being effective you must do more: make the appointment, go with them, fill out the forms, and follow up afterward.
This is what Reema does.
Social Needs are Health Needs
I am Dr. Ramsey Peterson. In addition to being the Chief Medical Officer for Reema Health, I also practice as a primary care physician. In this role, I pride myself on managing my patients’ chronic and acute conditions, providing preventative medicine, and building relationships with patients and understanding their needs. However, I also understand my limitations, and I refer my patients to a number of other services, including physical therapists, mental health providers, and many other specialists to address their needs.
Early in my career I realized that to improve physical and mental health over the long term, it was critical to address the patient’s social needs. I began referring patients to social care specialists as well. Thankfully, there are a number of companies focused on building a network of social care organizations that make those referrals easier. These companies (and their success) represent some of the progress we have witnessed from researchers, clinicians, payers, and providers as well as entrepreneurs and investors who are connecting social care to health care in hopes of more meaningful outcomes.
Social needs tools allow me to screen patients and then refer them to relevant resources. Screening patients has opened my eyes to unseen or previously unidentified needs, even in patients that I’ve seen for years. Many of my patients find the list of resources for social needs quite useful. Yet there is also a portion of patients for whom a screening and referral simply aren’t enough. To effectively decrease social need, patients require navigation services to help them access the resources to which they’ve been referred.
Refer and Accompany
I have encountered this first hand in my practice. A social determinants screening helped me discover that a recent patient was experiencing domestic violence. I referred her to an organization that could help, but she did not take action on the referral because she was understandably, too scared. Even after I attempted to support and encourage her, she still did not take the steps to get herself and her kids to a safe place. During a later visit, a nurse sat in the room with her as she recounted her experience. This nurse was able to build trust because she had a shared experience and shared identity. Together they decided they would call a shelter that specialized in domestic violence. My patient got the help she needed and is no longer in her dangerous living situation.
Yet it wasn’t until a nurse in my office went on the journey with her, walked beside her, supported her, related with her, and ultimately sat with her while she made the call that she got the help she needed.”
For this patient the referral and my encouragement weren’t enough. One would hope that because her physical safety was at risk, she would have been motivated to follow up on the referral I made. Yet it wasn’t until a nurse in my office went on the journey with her, walked beside her, supported her, related with her, and ultimately sat with her while she made the call that she got the help she needed.
Unfortunately, this type of experience is true for a large portion of the population. While some patients who receive a referral follow up immediately and quickly receive help, others need additional support to ultimately access the resources they need.
Making Referrals Actually Work
Healthcare systems have improved how they approach the social needs of their patients by referring them to resources that might help. Though lots of companies provide the data for these referrals, for many patients, referrals alone aren’t enough. Simply making a referral often increases social need as opposed to decreasing it. In these cases, the referral is just the first step, and you need to take the next steps with your patient for the referral to have a real chance of being effective. Make the appointment. Go with them. Fill out the forms with them. Follow up afterward. If it doesn’t work, make another referral and walk the path with them all over again.
At Reema, we focus on serving those who require more than just a referral by employing the elements that were evidenced by my patient, connecting through shared experiences and shared identities, accompanying, supporting, relating, and doing things with and on behalf of the people we serve. Ultimately, authentic relationships will win every time over a basic referral.
