CPC + CBEx 2024: Pathways for Social Needs Assessment and Care

In a session at the 2024 Clinical Pathways Congress + Cancer Care Business Exchange, panelists Todd Goldstein, MHA, Specialist, Enterprise Change Management Memorial Sloan Kettering (MSK) Cancer Center; Norm Shore, Chief Executive Officer, Patient Discovery; and Alan Balch, PhD, Chief Executive Officer, Patient Advocate Foundation, went over the importance of social needs assessment and care in oncology and provided an example of pathways that help in providing these services to patients.

The discussion began with one of the panelists breaking down social needs that patients have that can become a barrier to them to adhering to care, accessing care, and how they can ultimately affect their outcomes of care. In generally, the top needs are housing, utilities, disability enrollment, enrollment and insurance, and transportation.

While integrating patients’ needs into the clinical workflow and the electronic medical record (EMR) is necessary, whole person care should be incorporated from the beginning of the care experience and requires human exchange. Having conversations with patients are important to build trust with their provider, but word choice and timing of these conversations is important so as not to offend the patient.

“When we're talking about social needs care, patients have to feel respected and listened to, and they have to feel a personal connection… When you do that right, especially when done in the context of key decision points—like care selection, care planning, care management—you can actually create a really good experience for patients and build trust,” said Dr Balch.

However, technological tools and pathways can help care teams better understand what patients are struggling with outside the clinical setting. Patient Discovery, for example, is a software platform tool for social needs and assessment care used by MSK. It is personalized for each patient and adapts to their needs. The patients are able to use the platform at home and self-report their health-related social needs (HRSNs) before each appointment. The care team then reviews the HRSNs, followed by performing a social needs assessment where they place orders for additional referrals and support services. A resolution plan is then implemented to ensure the patient’s needs are addressed.

MSK found that using this platform within the Bone Marrow Transplant (BMT) Service improved care team deficiencies by removing the burden of discovery from the “often-stretched” care teams and enabled efficient needs resolution throughout patients’ BMT treatments. Additional findings showed that socials workers and patient navigators were not overwhelmed, and providers and patients reported high satisfaction. Due to these positive results, MSK plans to expand their program to community oncology referral partners.

The speakers suggest that when creating a social needs care pathway, the following should be considered: (1) The pathway should be comprised of shared decision-making, care planning, and patient-reported outcomes; (2) patient information and insights should be gathered efficiently and effectively directly from them; and (3) highly personalized social needs care should be delivered based on the solutions most likely to improve outcomes and patient quality of life.

“We often get hung up on thinking that maybe needs navigation is the solution. Needs navigation is only good as your ability to actually navigate someone to a safety net,” said Dr Balch.

Reference

Goldstein T, Shore N, Balch A. Pathways for Social Needs Assessment and Care. Presented at the Clinical Pathways Congress; September 7, 2024; Boston, MA.