Overview
This resource provides a practical framework for designing and improving programs that connect patients with services addressing non-medical needs. It focuses on understanding the full pathway from identifying a need to successfully connecting a patient with an appropriate community resource.
What the Resource Covers
The article presents a “pathways strategy” that helps organizations map the ecosystem in which a social needs program operates, including the people, organizations, processes, and relationships that influence whether patients ultimately receive services. It outlines four core steps: engaging patients and other stakeholders; defining program goals and mapping each step in the referral pathway; identifying and reducing points where participants may drop off; and measuring successful connections at each stage. The resource also uses examples and well-developed figures to illustrate how a typical program workflow can be mapped and assessed.
Key Takeaways for Implementation
Organizations can use the pathway model to identify where referral processes are breaking down and where changes may improve successful connections to services. The framework is useful both for designing new programs and for evaluating and improving existing ones.
Who May Find This Resource Useful
This resource may be especially useful for health systems, health plans, and community partners seeking clear, detailed steps and visual models for designing, implementing, or improving programs that address non-medical needs.
Resource Type: Commentaries & Blogs; Tools & Toolkits.
Topic Areas: Program design, referrals, community services, workflow mapping, program evaluation.
Population or Setting: Health care organizations and cross-sector social care programs.
Publication Date: 2023.
Source: NEJM Catalyst Innovations in Care Delivery.
