The Aunt Bertha Blog

Why do hospitals struggle to manage social needs of patients?

At Aunt Bertha, we continually are on the lookout to understand what does and does not work when it comes to helping people in need connect with social services, which led us to conduct a survey of hospital executives through our partnership with GLG Social Impact. The survey assessed hospital executive’s perspectives on the role that community-based social services play in supporting their missions and their capacity to connect and track when these services are received.  The survey shows that 95% of hospitals face difficulties with tracking and measuring utilization of referrals to social need-based agencies and 60% of hospitals do not have a solid tracking method in place.

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Perspectives on Social Needs in Communities

The need for help is not limited to the income level of the patient.  While all hospitals had patients in need, more than 20% of population needs additional support at 63% of the hospitals studied. When hospital executives were asked how they would describe a patient population that needs social help,  the reasons went far beyond income.  A lack of caregivers at home, an aging population, a lack of support once a patient leaves the hospital, and a lack of knowledge of services available to help were all cited.  Each patient population has a unique combination of needs that a hospital has to serve and monitor.



Why does a systematic approach to connecting patients with social resources matter?

Hospitals are facing increasing pressure to focus on long-term clinical outcomes as quality measurement, pay-for-performance and other value-based purchasing strategies become the norm. In particular, the readmission penalties being applied by Medicare create substantial incentives for hospitals to take a more holistic view of the patient upon discharge, including addressing the social determinants of health.

The focus on addressing the social determinants of health is growing, and is expected to become increasingly important over the next 5 years.  The survey showed that 94% of respondents indicated it is important or very important to connect patients with social programs.  Respondents also closely align connecting patients with social resources to their organizational goals. 50% of respondents indicated improvements in this area will be critical to their long term success and another 33% indicated that they will become more important. However, as the survey indicates, most hospitals do not have a systematic process for making these connections and little is being tracked.

The time spent finding resources matters as well for a busy care management team.  A recent McKinsey study showed that employees spend an average of 9.3 hours per week looking for information. Until recently there were no consistent and systematic methods for hospitals to find community-based social service programs and track patient referrals to these programs, which leads to a resource burden.

Where does the difficulty in implementing a systematic approach and tracking lie?

Approaches implemented in the past by hospitals to address the social needs of their patients were informal and unstructured.  Respondents indicated that the most common methods for identifying social services agencies were information maintained on personal lists and Google searches.

Despite significant awareness of patient needs for social supports by hospital executives, more than 70% of respondents indicated that they either had a process for making referrals to social service agencies that was not systematic or that they had a systematic process that was underutilized.  About 60% of respondents indicated that utilization of referrals to social services was either not tracked and measured at all, or was tracked poorly and in a decentralized fashion.  An even higher percentage (about 65%) gave the same responses with respect to the tracking of outcomes from referrals to social services.

The most common explanation for not providing more navigation services to social programs was that it takes too much staff resources.  In addition, more than half of respondents identified the lack of software or a tool to find resources as the primary reason for not having a more systematic approach to tracking social needs support.

Best practices for Social Need referrals and outcomes 

Hospital executives recognize the need to address the social needs of their patients but are not doing so in a systematic way because they lack the tools and the data they need to support their efforts.  There are great advances in these capabilities, and the following best practices should be in place as part of any systematic approach for making referrals and tracking outcomes:

  1. Have a centralized system that makes it easy to find social program resources 
    Care management teams are extremely busy, so any new solutions must be easy to use and save time or there will be challenges with user adoption.  Making sure a solution is easy to use will not only promote adoption among a care team but also allow more staff members, such as front desk staff at a provider’s office, to help navigate patients to resources as well.
  2. Make sure program data is up to date and accurate.  
    A social program database must have depth of agency listings and be up to date and accurate.  This will also promote adoption and usage of the solution and avoid situations where trust is lost with the patient if a referral is made with inaccurate information.  
  3. Empower patients to self navigate 
    There will be times when a patient has a new social need that happens when they are not engaged with a staff member.  There may also be sensitive needs with relation to human service needs that patients are not comfortable sharing with hospital staff.   Empowering patients to self navigate solves these challenges and still allows for information to be collected on human service needs.
  4. Collaborate with the social program agencies you are referring patients to 
    Nonprofit and government human service agencies have their own missions and goals, many of which align with the missions and goals of hospitals.  Both have missions that center on helping people in need to achieve better outcomes.  Collaborating with local agencies to refer patients into can help in meeting patient’s humans service needs and in some cases help with referrals tracking.
  5. Create reporting that shows which referral activities are impacting outcomes.
    A centralized human service referral system can provide a wealth of data that includes specific areas of human service needs for your patient population, which agencies are being referred most often and how many times they were able to provide help, and which employees are regularly making referrals.  Tieing this information to patient health data can show which human service activities are having the greatest impact, guiding best practices for staff members.  

How can Aunt Bertha help?



Extensive, easy-to-navigate data

Aunt Bertha's software for hospitals and health plans helps to more effectively and efficiently connect patients to agencies that assist with food, housing, transportation, and other services.  This provides a quick and consistent process for social program referrals.  

The interface is also easily used by patients who are ready to self-navigate the process.


data-dashboards-600.pngReporting and collaboration capabilities

All activity is recorded so referrals and areas of greatest need for a patient population can be seen in real time in our analytics dashboard, allowing executives to spot trends, analyze gaps and determine which social interventions have the greatest impact.  




Download Study and Best Practices Request a demo ›

Topics: reporting analytics social determinants of health