TY - JOUR
AU - J. D. Ralston
AU - K. S. Gleason
AU - E. A. Bayliss
AU - K. Estacio
AU - L. Healy
AU - E. Holden
AU - J. McCloskey
AU - I. Peterson
AU - L. Shulman
AU - T. Taylor-McPhail
AU - C. S. Uratsu
AU - R. W. Grant
A1 - 
AB - BACKGROUND: Unmet social needs are common among individuals with multiple chronic health conditions (MCC). OBJECTIVE: To evaluate the acceptability of proactive outreach to assess and follow up on social health needs among patients with MCC. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: We interviewed 25 patients with 2 or more chronic health conditions in three integrated care settings in Washington, Colorado, and California that experienced proactive outreach offering assessment and follow-up for social health risks. All patients had a higher likelihood of social health risks based on a predictive model using health plan and electronic health record data. Patients received initial outreach from clinical pharmacists at the Northern California site, licensed practical nurses in primary care at the Washington site, and Community Specialists at the Colorado site. APPROACH: Transcripts were analyzed using a mixed deductive and inductive thematic approach informed by the Theoretical Framework of Acceptability. KEY RESULTS: Mean age across the groups was 66 years. We identified five themes common across all three healthcare sites. Participants appreciated the outreach, stating they felt understood and cared for by their providers; recognized how their social needs were intertwined with their physical and mental health; and found that uncomfortable social health conversations were easier with known healthcare providers. Assessment of social health needs and referral to community resources provided some participants with hope that their needs would be met, while others felt discouraged by prior experience. Following referral to community resources, participants had uneven experiences receiving resources to address their needs. CONCLUSIONS: Our results suggest proactive outreach by healthcare team members to assess and address social health needs is valued by patients with MCC despite challenges with accessing some social health resources. Future work is needed to support access to community resources and evaluate the outcomes of outreach to those with MCC who have social needs.
AD - Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, 1730 Minor Avenue, Suite 1360, Seattle, WA, 98101-1466, USA. James.D.Ralston@kp.org.; Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.; Division of Research, Kaiser Permanente Northern California, Pleasanton, CA, USA.; Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, 1730 Minor Avenue, Suite 1360, Seattle, WA, 98101-1466, USA.
AN - 40562889
BT - J Gen Intern Med
C5 - Education & Workforce
DA - Jun 25
DO - 10.1007/s11606-025-09650-z
DP - NLM
ET - 20250625
JF - J Gen Intern Med
LA - eng
N2 - BACKGROUND: Unmet social needs are common among individuals with multiple chronic health conditions (MCC). OBJECTIVE: To evaluate the acceptability of proactive outreach to assess and follow up on social health needs among patients with MCC. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: We interviewed 25 patients with 2 or more chronic health conditions in three integrated care settings in Washington, Colorado, and California that experienced proactive outreach offering assessment and follow-up for social health risks. All patients had a higher likelihood of social health risks based on a predictive model using health plan and electronic health record data. Patients received initial outreach from clinical pharmacists at the Northern California site, licensed practical nurses in primary care at the Washington site, and Community Specialists at the Colorado site. APPROACH: Transcripts were analyzed using a mixed deductive and inductive thematic approach informed by the Theoretical Framework of Acceptability. KEY RESULTS: Mean age across the groups was 66 years. We identified five themes common across all three healthcare sites. Participants appreciated the outreach, stating they felt understood and cared for by their providers; recognized how their social needs were intertwined with their physical and mental health; and found that uncomfortable social health conversations were easier with known healthcare providers. Assessment of social health needs and referral to community resources provided some participants with hope that their needs would be met, while others felt discouraged by prior experience. Following referral to community resources, participants had uneven experiences receiving resources to address their needs. CONCLUSIONS: Our results suggest proactive outreach by healthcare team members to assess and address social health needs is valued by patients with MCC despite challenges with accessing some social health resources. Future work is needed to support access to community resources and evaluate the outcomes of outreach to those with MCC who have social needs.
PY - 2025
SN - 0884-8734
ST - Outreach Assessment for Social Health Needs in Patients with Multiple Chronic Conditions: Qualitative Study of Patient Experience
T1 - Outreach Assessment for Social Health Needs in Patients with Multiple Chronic Conditions: Qualitative Study of Patient Experience
T2 - J Gen Intern Med
TI - Outreach Assessment for Social Health Needs in Patients with Multiple Chronic Conditions: Qualitative Study of Patient Experience
U1 - Education & Workforce
U3 - 10.1007/s11606-025-09650-z
VO - 0884-8734
Y1 - 2025
ER -