Implementing a social needs screening and referral program for obstetrics and gynecology patients

Abstract

Background

Health-related social needs (HRSNs) contribute to poor obstetrics and gynecology (OB/GYN) outcomes. Community health worker (CHW) interventions are a promising model for connecting patients with social resources, improving patient outcomes, and advancing health equity; however, limited research exists evaluating such interventions in OB/GYN practices.

Objective

We aimed to describe the implementation of a novel program for OB/GYN patients that included standardized HRSN screening and referral to CHWs.

Study Design

This was a retrospective cohort study of patients seen by CHW-supported OB/GYN clinical practices who completed a standardized HRSN screener between June 2022 and May 2024. Patients who were screened and/or self-reported unmet HRSNs were eligible for referral to CHWs by their clinician. We used descriptive statistics to assess RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes and socio-demographic characteristics of patients.

Results

Of 11,191 OB/GYN patients screened, 1,871 (16.7%) reported unmet HRSNs. There were 944 patients with outreach attempted by CHWs, of which 696 (73.7%) consented to work with CHWs. Overall, 93.5% of patients were connected or equipped to connect to social services and 92.7% reported improvement or resolution of HRSNs. Referral rates varied by clinical team (median 22.3%, IQR 15.5-30.9%), with a median of 8 days (IQR 3-19 days) between referral and first CHW contact. The median annual program cost per patient was $289.07 (IQR $230.17-$431.91).

Conclusion

This HRSN screening and referral program was highly effective in connecting referred OB/GYN patients with unmet HRSNs to relevant social services. Addressing patients’ unmet HRSNs may allow patients to better engage in OB/GYN care and improve clinical outcomes.

Introduction

Social determinants of health, the conditions in which people are born, grow, work, and age (Office of Disease Prevention and Health Promotion, n.d.), shape access to care (Whitman et al., 2022) and influence up to 50% of a patient’s health (University of Wisconsin Population Health Institute, 2015). These factors contribute to the ongoing maternal health crisis, which is also driven by delays in childbearing, increases in chronic disease prevalence, and poor access to high-quality health care (Howell, 2018). Adverse social determinants of health contribute to the significant racial disparities in obstetric outcomes; Non-Hispanic Black individuals are 2-3 times more likely to experience maternal mortality (Hoyert, 2024) and twice as likely to experience severe maternal morbidity compared to non-Hispanic white individuals (Declercq & Zephyrin, 2021). Unmet social needs also increase the risk of unintended pregnancy, infertility, and cervical cancer (Cronin et al., 2024).

Health-related social needs (HRSNs) refer to an individual’s unmet material conditions, such as food insecurity or poor housing quality, that may impact health (CMS, 2024). Awareness of and assistance with unmet HRSNs are vital to improving the delivery of care (NASEM, 2019). Screening during pregnancy, the postpartum period, and gynecologic care can identify reproductive-aged patients with unmet HRSNs and facilitate referral to resources, such as community health workers (CHWs). CHWs are frontline public health workers with a deep understanding of the community (American Public Health Association, n.d.). They are trusted by patients and help bridge the gap between healthcare and social services (Brown et al., 2020). CHW interventions are effective in improving care, reducing costs, and advancing healthy equity in primary care settings (Knowles et al., 2023). Prior work has demonstrated the value of CHW programs in perinatal and early childhood care (Cunningham et al., 2020; Moheize et al., 2024; Mundorf et al., 2018); however, few studies have embedded CHWs directly within routine obstetrics and gynecology (OB/GYN) practices using standardized screening for HRSNs and systematic follow-up of referrals. In this study, we describe and evaluate a health system’s 2-year experience screening OB/GYN patients for unmet HRSNs and integrating CHWs within those care teams to address them.

Materials and Methods

Intervention

The Community Health Worker Institute (CHWI) was established in June 2022 to optimize the integration of CHWs into clinical care teams and promote health equity (Fiori et al., 2024). The CHWI recruits and deploys CHWs within a large urban health system and provides 4 weeks of standardized on-the-job training focused on patient engagement, electronic health record (EHR) documentation, and HRSN navigation. The CHWI also provides CHWs with opportunities to obtain certificates and college credits from an accredited apprenticeship program within a local community college. CHWs are hired as full-time employees who have expertise and share lived experiences with communities they serve. Most CHW positions require a high school diploma or equivalent. CHWs integrate social and clinical care for patients with unmet HRSNs by providing social service navigation and improving healthcare access within their assigned clinical practices. CHW salaries are supported through grant funding, and their navigation services are not reimbursed by insurance payers. Implementation of the CHWI was previously examined in primary care settings, in which 70% of referred patients successfully connected with a CHW and 93% of those connected to social services reported improvement or resolution of their HRSNs (Fiori et al., 2024). However, this is the first evaluation of CHW deployment in OB/GYN practices within our health system.

The CHWI supports four clinical care teams within the Department of Obstetrics, Gynecology and Women’s Health. As part of the health system’s focus on health equity, it is recommended that patients be screened for unmet HRSNs within these clinical practices during specific visit types including: 1) new obstetric visits, 2) new gynecology visits, 3) annual gynecology visits, and 4) postpartum visits. Screening occurs through a self-administered 10-item tool, adapted from the Health Leads Screening Toolkit (HealthLeads, 2023) and integrated into the EHR in 2018 (Figure 1). For any patient who screens positive for one or more unmet HRSN, clinicians are instructed to review the screener results and confirm patient interest in receiving assistance. Upon confirmation, the clinician places an EHR referral order to a CHW. Clinicians can also provide direct assistance using the EHR-supported social service directory (findhelp, 2024). Patients may also be referred to CHWs based on clinicians’ discretion regardless of whether they were formally screened for unmet HRSNs.

Figure 1. Health-Related Social Needs Screening Tool*.

*In September 2023, the heath system removed the HRSNs screening question focused on interpersonal conflict (question 9) after discussions with key stakeholders due to conflicting interpretation by patients and clinicians.

In addition to the generalized OB/GYN program described above, there is a specialized program within one of the four clinical practices, which was also established in June 2022. Through this program, a specialized high-risk pregnancy CHW provides tailored care coordination in addition to routine HRSN navigation services to postpartum patients with high-risk pregnancies at a dedicated postpartum clinic, the Postpartum High-Risk Optimization, Empowerment and Networking Experience (PHOENIX) (Vani et al., 2024). In this clinic, the CHW proactively identifies eligible patients based on postpartum risk status, completes HRSN screening during an intake assessing postpartum needs, and provides both care coordination and HRSN navigation under the supervision of a maternal-fetal medicine specialist. Referrals in the high-risk clinic occurred through direct engagement with the patient rather than an EHR referral order. The high-risk CHW is trained in HRSN navigation the same as other CHWs and provides similar services and follow-up.

Study Design and Data Sources

We conducted a retrospective study using HRSN screening and clinician referral order data collected in the EHR and CHW navigation data collected and managed in the CHWI Research Electronic Data Capture (REDCap) database (Fiori et al., 2024; Harris et al., 2009). The REDCap database was internally developed and designed for CHWs to routinely collect data on patient demographics, referral information, outreach encounters, HRSN services provided, and key program outcomes. Data was extracted from the EHR using Microsoft SQL Server, version 18, to query data from the Epic Electronic Health Record Data Warehouse.

Study Measures and Analysis

We organized and evaluated study measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains (Table 1) (Glasgow et al., 2019). We used descriptive statistics to summarize RE-AIM process and outcome measures and socio-demographic characteristics of patients who worked with a CHW. All statistics were generated in SAS version 9.4 and weighted estimates for the maintenance measure were calculated using PROC MEANS (Inc, 2015). This study was approved by the Albert Einstein College of Medicine Institutional Review Board (2017-8434).

Table 1.

Community Health Worker Institute (CHWI) Program Components, Measures, and Key Data Sources Organized by RE-AIM.

Components	Measures	Key Data Sources
Reach	R1 (Screening): Percentage of active patients who were screened for unmet HRSNs R2 (Navigation): Percentage of patients outreached by CHWs who consented to CHW assistance	EHR HRSNs screening database CHWI REDCap database
Effectiveness	E1 (Navigation): Percentage of assisted patients connected or equipped to connect to at least one social service E2 (Navigation): Percentage of patients connected to service who self-reported resolution or progress on at least one HRSN	CHWI REDCap database
Adoption	A1 (Screening): Percentage of active patients who were screened for unmet HRSNs by clinical practice A2 (Referral): Percentage of patients screened positive for unmet HRSNs who were referred to a CHW via EHR by clinical practice	EHR HRSNs screening database EHR referral order database CHWI REDCap database
Implementation	I1 (Navigation): Percentage of patients referred to a CHW via electronic health record referral order with outreach attempted by a CHW (if applicable) I2 (Navigation): Median time, in days, between the electronic health record referral order and first CHW outreach attempt (if applicable)	EHR referral order database CHWI REDCap database
Maintenance	M1 (Navigation): Median annual cost per beneficiary required to implement and sustain the OB/GYN CHWI program	Health system operations budget CHWI REDCap database

Abbreviations: RE-AIM = Reach, Effectiveness, Adoption, Implementation and Maintainenace, EHR = Electronic Health Record; HRSN = Health-Related Social Need; REDCap = Research Electronic Data Capture; CHW = Community Health Worker

Reach

Reach was evaluated with two measures: R1) the proportion of eligible patients who were screened for unmet HRSNs (i.e., screening rate) and R2) the proportion of patients outreached by CHWs who consented to CHW assistance with HRSNs (i.e., those working with a CHW). The screening rate was calculated as the number of unique patients screened for unmet HRSNs between June 2022 and May 2024 divided by the number of eligible patients during the same time. Eligible patients were defined as those who visited one of four CHWI-supported OB/GYN clinical practices with a visit type designated for HRSN screening.

Effectiveness

Our primary effectiveness measure (E1) was the proportion of patients assisted with unmet HRSNs who were connected to or equipped with the tools to connect to at least one social service on their own. Patients who were equipped were screened for service eligibility and provided with all the necessary information to connect to services, such as appropriate instructions, documentation, phone number, and location. This CHW-reported measure represents whether the CHW successfully completed all necessary steps, per program workflows, to refer patients to available services. Our secondary effectiveness measure (E2) was the proportion of patients reporting connection to social services who resolved or made progress on at least one unmet HRSN. This patient-reported measure is only documented for patients who reported receiving a service. We compared effectiveness measures between the high-risk specialized CHW and general OB/GYN CHWs. All measures and definitions were internally developed by the CHWI and applied to all social services and needs for all supported CHW programs across the health system (Supplemental Table 1).

Adoption

We evaluated the adoption of our program as (A1) the proportion of eligible patients who were screened for unmet HRSNs by clinical practice and (A2) the proportion of patients screened positive for unmet HRSNs who were referred to CHWs via the EHR by clinical practice. These measures aimed to assess differences in the clinical staff’s adoption of recommended program screening and referral workflows. Patients who engaged directly with the high-risk specialized CHW were not included in measure A2 because they were not referred by clinicians via EHR.

Implementation

Implementation measures evaluated the extent to which CHWs adhered to the recommended referral workflows. These measures included (I1) the proportion of patients referred via the EHR with attempted outreach by a CHW, and (I2) the median time, in days, between the clinician’s EHR referral order and the first CHW outreach attempt. Patients who engaged directly with the high-risk specialized CHW were not referred via the EHR and thus were not included in these measures. The first implementation measure matched unique patient identifiers between the EHR and REDCap databases to calculate the proportion of patients who were both referred and outreached. The second measure calculated the difference in days between the referral date in the EHR and the date of first outreach in REDCap. If the outreach attempt was dated prior to the referral date, the patient was excluded. If there was a documented "warm handoff," or direct, same-day transfer of care, the patient was assigned a difference of 0 days, to override delays in clinician EHR documentation. The median difference, in days, across the study population was compared to the CHWI operational expectation to complete first outreach within 7 days of the referral date.

Maintenance

We defined maintenance as the annual cost per beneficiary required to implement and sustain the OB/GYN CHWI program, which has implications for future reimbursement opportunities and internal funding. We first calculated the annual cost per beneficiary for each CHW active in the OB/GYN program as the total cost per CHW per year divided by the number of new OB/GYN patients outreached per CHW per year. The total cost per CHW per year was calculated based on standardized annual salary estimates prorated according to the number of months each CHW was active in the OB/GYN CHWI program. We then calculated the median cost per beneficiary across CHWs and program years and applied weights to account for differences between CHWs. Weights measured 1) the number of months each CHW was active in the OB/GYN CHWI program per year divided by the total number of months per program year (n=12) and 2) the number of new OB/GYN patients outreached per CHW per year divided by the total number of new patients outreached across clinical settings per CHW per year. CHWs may not be deployed during the entire program year and may support patients across clinical settings. The use of weights allows CHWs who are more active in the OB/GYN CHWI program to contribute more to the median calculation.

Results

Reach

Between June 2022 and May 2024, there were 11,191 patients screened for unmet HRSNs within the four CHWI-supported OB/GYN clinical practices, which represents 43.4% of the 25,815 patients with eligible visits (R1). There were 226 patients who declined to complete the HRSN screener during the study period. Of those screened for HRSNs, 1,871 (16.7%) screened positive for at least one unmet HRSN. There were 944 patients with outreach attempted by CHWs in the REDCap database who were documented as being referred from OB/GYN clinical practices. Of these patients, 587 (62.2%) were referred via EHR from general OB/GYN practices, 64 (6.8%) were referred without an EHR order from general OB/GYN practices, and 293 (31.0%) were directly engaged by the embedded high-risk specialized CHW in the PHOENIX clinic. 458 (48.5%) of these patients screened positive for unmet HRSNs, 239 (25.3%) screened negative for unmet HRSNs, and 247 (26.2%) were not screened, as documented in the EHR. Of the 247 patients who were not screened in the EHR, 85 worked with the high-risk specialized CHW who documented screening results directly in the REDCap database. Among these patients, 56 (22.7%) screened positive, 18 (11.3%) screened negative, and 11 (4.4%) either were not screened or had missing data. 293 (31.0%) of the total patients with outreach attempted by CHWs were first engaged by the high-risk specialized CHW.

Of the 944 patients outreached by CHWs, 837 (88.7%) were successfully contacted. The remaining patients were either disconnected after three or more unsuccessful initial outreach attempts (n=101, 10.7%) or are still awaiting successful initial contact by a CHW (n=6, 0.6%) (Figure 2). 696 (73.7%) patients were successfully contacted and consented to work with a CHW to address unmet HRSNs (R2). Additional patients were successfully contacted but declined CHW assistance with unmet HRSNs (n=73, 7.7%), confirmed that they did not have unmet HRSNs (n=49, 5.2%), are awaiting follow-up contact to complete consent for HRSN navigation (n=6, 0.6%), or were disconnected prior to consent after three or more unsuccessful follow-up attempts (n=13, 1.4%).

Figure 2. Reach and Effectiveness of Health-Related Social Needs (HRSN) Screening and Referral to Community Health Workers (CHWs) for OB/GYN Patients.

We summarized the socio-demographic characteristics of patients working with a CHW (n=696) (Table 2). Median age at referral was 33.2 years (IQR 28.1-39.4). Most patients identified as Hispanic (49.3%) or non-Hispanic Black (30.5%). The primary preferred spoken language was English (70.0%), followed by Spanish (22.3%). Insurance data were only available for those who completed the formal HRSN screen in the EHR prior to CHW referral. The majority of patients had Medicaid listed as their primary insurance (58.3%). Among the patients assisted, there were 1,715 total unmet HRSNs reported, with food security (23.4%), housing security (15.6%), and youth and family services (15.3%) identified as the most prevalent unmet HRSNs (Table 3).

Table 2.

Descriptive Characteristics of Patients with Self-Reported Health-Related Social Needs Working with a Community Health Worker (CHW), June 2022-May 2024.^*

Measures
Total Number of Patients Working with a CHW	696 (100.0)
Age, years (median, IQR)	33.2 (28.1, 39.4)
Race and Ethnicity
Hispanic	343 (49.3)
Non-Hispanic American Indian / Alaskan Native	1 (0.1)
Non-Hispanic Asian / Pacific Islander	11 (1.6)
Non-Hispanic Black	212 (30.5)
Non-Hispanic white	12 (1.7)
Other	36 (5.2)
Declined to report	81 (11.6)
Preferred Spoken Language
English	487 (70.0)
Spanish	155 (22.3)
Bilingual, Spanish or English	15 (2.2)
Other Language	39 (5.6)
Primary Insurance at Screening
Commercial	64 (9.2)
Medicaid	406 (58.3)
Medicare	33 (4.7)
Other	20 (2.9)
N/A, Not screened	173 (24.9)

^*Data are n(%) unless otherwise specified

Table 3.

Self-Reported Health-Related Social Needs (HRSNs) of Patients Working with a Community Health Worker, June 2022-May 2024.

Measures	Total HRSNs identified (n, %)
Total HRSNs	1,715 (100.0)
Housing Security	267 (15.6)
Housing Quality	87 (5.1)
Employment	25 (1.5)
Financial Benefits	214 (12.5)
Food Security	401 (23.4)
Care Coordination and Navigation	240 (14.0)
Referral to Health Homes Program	4 (0.2)
Legal Services	56 (3.3)
Youth and Family Services	262 (15.3)
Referral to Primary Care Provider	140 (8.2)
Other Need	19 (1.1)

Effectiveness

651 (93.5%) of the 696 patients working with a CHW were connected (n=438) or equipped to connect (n=213) to at least one social service (E1) (Table 1). After at least 6 months of follow-up, 40 (5.7%) patients were still actively working with a CHW to connect to services and 5 (0.7%) patients failed to connect to services or were lost to follow-up before services were rendered or connection confirmed (Figure 2). Connection and equipped connection rates were higher for patients outreached by the high-risk specialized CHW (99.1%) compared to CHWs at general OB/GYN practices (90.8%).

Of those who were connected to at least one social service (n=438), 406 (92.7%) patients self-reported that at least one unmet HRSN was improved or resolved (E2). There were 32 (7.3%) patients who self-reported no progress on their unmet HRSNs or were lost to follow-up before progress was made, after at least 6 months of follow-up. Resolution and progress rates were also higher for patients outreached by the high-risk specialized CHW (100.0%) compared to CHWs at general OB/GYN practices (85.1%).

Adoption

Of the four OB/GYN clinical practices that adopted the HRSN screening intervention, the median screening rate was 39.5% (IQR 26.2-69.5%) with a range of 21.9%-123.9% of eligible patients screened for unmet HRSNs during the study period. The clinical practice with a screening rate of 123.9% did not limit screening to eligible visits only, which accounts for the screening rate above 100%. Across the clinical practices, the median EHR referral rate was 22.3% (IQR 15.5-30.9%) with a range of 15.2-36.5% of patients screened positive (n=1,831 general OB/GYN patients) who were referred via EHR to a CHW (n=432 general OB/GYN patients).

Implementation

There were 667 patients with EHR orders sent by clinicians from general OB/GYN clinical practices. Of those referred via EHR, 587 (88.0%) patients had at least one outreach attempt documented in the CHWI REDCap database, with the remaining 80 (12.0%) patients not contacted yet. In the time to outreach analysis, 10 of the 587 patients were excluded because their first contact attempt was dated prior to the EHR order. Of those included (n=577), there were 21 patients who were assigned a difference in days of 0 because they had a documented warm handoff, in which clinicians and CHWs saw the patient on the same day. The median time for CHWs to complete the first contact attempt was 8 days (IQR 3–19 days) after the electronic referral order date, compared to standard CHWI expectation of 7 days.

Maintenance

We included four CHWs in our evaluation of the annual cost per beneficiary to implement and sustain the OB/GYN CHWI program. The median annual cost per patient across the 24-month study period was $289.07 (IQR $230.17-$431.91), after applying analytic weights.

Discussion

In this study, we evaluated the implementation and early process outcomes of a program that systematically screens patients for unmet HRSNs during routine OB/GYN visits and connects them to CHWs for social service navigation. Despite variation in implementation between general OB/GYN practices and the specialized postpartum (PHOENIX) clinic, nearly all patients with unmet HRSNs referred to CHWs were successfully contacted and consented to work with a CHW. Among those engaged, 94% were connected or equipped to connect to at least one social service. These results demonstrate that standardized screening and referral workflows, when supported by embedded CHWs, can be feasibly implemented in OB/GYN settings and effectively address patients’ HRSNs, laying essential groundwork for improving maternal and reproductive health outcomes. By integrating CHWs into routine OB/GYN care, health systems can operationalize social-care screening and navigation at scale, potentially improving patient engagement and reducing disparities.

Previous literature primarily describes HRSN screening tools or interventions implementing screening among OB/GYN patients, but not referrals to services (Joseph et al., 2023; Peahl et al., 2024; Peahl et al., 2023). In those studies, the reach of the HRSN screening interventions varied greatly, with 40 to 75% of patients screened (Joseph et al., 2023; Peahl et al., 2024; Peahl et al., 2023). Our program likely observed lower screening rates (43.4%) than those reported in other studies because of limited implementation of the standardized screening workflow. The 17% of our screened participants reporting unmet HRSNs was much lower than the 45-77% range reported in the OB/GYN literature but comparable to the 7-25% reported by the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS) for the general adult population (Town et al., 2024). This difference may be related to the screening questions administered. For example, the BRFSS question about loneliness and the question about the need for infant supplies from the study by Peahl et al. are not in our screening tool but may be more relevant for OB/GYN patients (Peahl et al., 2023; Town et al., 2024).

Few studies describing HRSN screening explain how unmet HRSNs were addressed or resolved (Joseph et al., 2023; Lee King et al., 2024). Cordova-Ramos et al. (2023) describe the implementation of a closed-loop referral system within a neonatal intensive care unit in which referrals were completed for 98% of families with unmet HRSNs and 50% of families were connected to resources. Our EHR-referral rates were approximately 22%, reflecting differences between the standardized screening-and-referral workflow and real-world practice. In the general OB/GYN practices, referral completion required clinician review of the screen and placement of an EHR referral order, introducing multiple steps during time-constrained visits. Referral rates at these practices may have been low due to lack of awareness of the EHR referral order or difficulty completing the referral workflow in a busy outpatient setting; also, some patients may have declined services, but we did not collect data on the frequency or reasons for declining. Consistent with these barriers, clinicians in our outpatient practices have previously reported being unable to fully review positive HRSN screens due to limited time (George et al., 2025). In contrast, the PHOENIX clinic’s workflow allowed for the high-risk specialized CHW to directly identify and support patients without an EHR order. As a result, these referrals were not included in the adoption and implementation measures, and the true referral rate is likely underestimated. These workflow barriers suggest that greater embedding of CHWs into routine clinical workflows may facilitate more consistent referral completion. Despite the low referral rates in our study, our CHWs were successful in connecting patients to services once they were referred: 63% of patients were connected to resources and an additional 31% were equipped to connect to resources on their own.

Strengths of our study include the implementation of an HRSN screening and referral program within a large urban health system serving a racially and ethnically diverse population. Despite the complexity of implementation across multiple independently operating OB/GYN practices, nearly all patients with unmet HRSNs referred to CHWs were connected to social services. Limitations include difficulty accurately estimating program reach due to variability in implementation of and adherence to the standardized workflow. Our data is also limited to aggregate OB/GYN patient counts, preventing comparisons between those screened and not screened. Patients who completed the screener may not have reported unmet HRSNs due to mistrust in the health care system (Armstrong et al., 2006). Referral rates varied widely, and patients were sometimes referred for CHW services without a documented positive screen or EHR order. Patients referred to the high-risk specialized CHW were not documented in EHR referral orders and, therefore, could not be included in our study’s adoption and implementation measures. Because our evaluation focused on implementation and process measures, we did not capture maternal or infant clinical outcomes. Future analyses linking HRSN referral and resolution data to health outcomes are warranted to assess downstream impact.

Another limitation is that screening and referral data were collected by non-research staff during routine care. Although investigators regularly reviewed data and implemented safeguards, misclassification bias may remain. Additionally, we lack data on patients referred to the EHR-supported social service directory when a CHW was unavailable. Finally, our measure of cost is likely overestimated compared to previous CHWI evaluations (Fiori et al., 2024) as it is based on patient volume, which correlates with lower screening and referral rates.

Implications for Practice and Policy

Unmet HRSNs adversely affect health outcomes in obstetrics and gynecology, including pregnancy outcomes, incidence of gynecologic cancer and infertility. Our implementation offers a strategy to screen OB/GYN patients for unmet HRSNs and address these needs through CHWs. While our ability to identify all patients with an unmet HRSN was limited, once a need was identified and a patient was successfully referred to a CHW, our program was able to connect or equip patients to receive needed social services.

Those seeking to implement a similar program should ensure processes are in place to optimize screening reach to achieve the maximum benefit for patients with unmet HRSNs. Implementation efforts should evaluate the barriers and facilitators to successfully identifying OB/GYN patients with unmet HRSNs to improve program reach and adoption. Moreover, there should be an evaluation of the association between patient characteristics and differences in rates of connection to services and resolution of needs by HRSN domain to determine if there are certain groups of people who should be targeted for intensified outreach. Qualitative investigation into patients’ reservations about disclosing unmet HRSNs and working with CHWs is also needed to develop patient-centered engagement strategies (Fiori et al., 2024). In addition to evaluating strategies to improve reach and adoption, further research is needed to determine whether connection to services through CHWs may lead to improved OB/GYN-related health outcomes, including maternal morbidity and mortality.

Sustainable financing will be essential to expand CHW integration. Several states, including California, Massachusetts and Minnesota, now reimburse CHW services through Medicaid waivers or state plan amendments. Adoption of similar policies in other states could support long-term implementation and scalability of OB/GYN CHW models (D’Alessandro et al., 2024; Haldar & Hinton, 2023).

Conclusions

To our knowledge, this is the first implementation evaluation of an HRSN screening and referral program within OB/GYN practices. Our evaluation demonstrated that while our reach for screening was limited, once OB/GYN patients were identified to have an unmet HRSN and referred to a CHW, there were very high rates of success in connecting them with the needed social services. Addressing unmet HRSNs may improve health outcomes and address health disparities in OB/GYN patient populations.

Abbreviations

HRSNs

Health-related Social Needs

CHW

Community Health Worker

OB/GYN

Obstetrics and Gynecology

CHWI

Community Health Worker Institute

EHR

Electronic Health Record

PHOENIX

Postpartum High-Risk Optimization, Empowerment and Networking Experience

RE-AIM

Reach, Effectiveness, Adoption, Implementation, Maintenance

Biographies

Kavita Vani, MD is an Assistant Professor in the Department of Obstetrics and Gynecology at Montefiore Einstein. Her research focuses on developing evidence-based, patient-centered care models for patients with high-risk pregnancies, particularly during the postpartum period.

Samantha Levano, MPH is a Senior Research Coordinator for the Community Health Systems Lab at Albert Einstein College of Medicine. She has expertise in statistical analysis, program evaluation, and implementation research and focuses on domestic and international community health programs.

Jessica Haughton, MA, MPH is a Principal Staff Scientist in the Department of Pediatrics at Albert Einstein College of Medicine. She uses qualitative methods to develop community-engaged research projects, test effective implementation strategies, and assess outcomes of multilevel evidence-based interventions.

Miya Lemberg, BS is a Senior Study Coordinator for the Community Health Systems Lab at Albert Einstein College of Medicine. Her research interests include the implementation of evidence-based interventions to address patients’ social needs and improve health outcomes.

Renee Whiskey-LaLanne, MPH, MCHES is the Associate Director of the Community Health Worker Institute at Montefiore Einstein. Her work focuses on the strategic development of community health worker programs to address social and health needs of underserved and vulnerable populations.

Kevin Fiori, MD, MPH, MS is an Associate Professor in the Department of Pediatrics and Director of the Community Health Worker Institute at Montefiore Einstein. His research focuses on integrating social needs screening and community health worker outreach.