A Proactive Telephonic Outreach Program to Address Unmet Social Needs of Children in Immigrant and Refugee Families at a Federally Qualified Health Center.

Objective: We developed a telephonic outreach and care coordination program for children in immigrant and refugee families (CIRF) at a federally qualified health center (FQHC) in North Carolina to address unmet health-related social needs (HRSN).

Methods: Participants were recruited between December 2020 and October 2021. Eligible children were ages 0-5, non-English speaking, and were seen at the FQHC in the 2 years prior.

A Tailored SMS Text Message-Based Intervention to Facilitate Patient Access to Referred Community-Based Social Needs Resources: Protocol for a Pilot Feasibility and Acceptability Study.

Background: Health care providers are increasingly screening patients for unmet social needs (eg, food, housing, transportation, and social isolation) and referring patients to relevant community-based resources and social services. Patients' connection to referred services is often low, however, suggesting the need for additional support to facilitate engagement with resources. SMS text messaging presents an opportunity to address barriers related to contacting resources in an accessible, scalable, and low-cost manner.

Training student volunteers as community resource navigators to address patients' social needs: A curriculum toolkit.

Introduction: Few resources are available to train students to provide patients assistance for obtaining needed community-based services. This toolkit outlines a curriculum to train student volunteers to become "community resource navigators" to serve patients telephone at partner health sites.

Methods: University students co-designed the Help Desk navigator program and training for volunteer navigators as part of an academic-community partnership with a local Federally Qualified Health Center (FQHC).

Implementation mapping for tobacco cessation in a federally qualified health center.

Background: Implementation mapping (IM) is a promising five-step method for guiding planning, execution, and maintenance of an innovation. Case examples are valuable for implementation practitioners to understand considerations for applying IM. This pilot study aimed to determine the feasibility of using IM within a federally qualified health center (FQHC) with limited funds and a 1-year timeline.

A Community Resource Navigator Model: Utilizing Student Volunteers to Integrate Health and Social Care in a Community Health Center Setting.

Introduction: While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work.

Addressing the Social Determinants of Health During the COVID-19 Pandemic: Ensuring Equity, Quality, and Sustainability.

The COVID-19 pandemic has highlighted the importance of social determinants of health in affecting health outcomes. Populations with high social risk are disproportionately impacted by the virus and its economic consequences. Primary care practices have a unique opportunity to implement interventions to mitigate their patients' unmet social needs, such as food and income insecurity.

Reaching the Hard-to-Reach: Outcomes of the Severe Hypertension Outreach Intervention.

Introduction: Severe hypertension (≥180 mmHg systolic or ≥110 mmHg diastolic) is associated with a twofold increase in the relative risk of death. At the authors' Federally Qualified Health Center in the Southeast, 39% of adults (n=8,695) had hypertension, and 3% (n=235) were severe. The purpose of this project was to lower blood pressure and improve the proportion of patients achieving the Agency for Healthcare Research and Quality goal for blood pressure.

Implementing standardized substance use disorder screening in primary care.

Objectives: This quality improvement initiative aimed to develop and implement a protocol for an alcohol and substance use disorder screening for primary care.

Methods: The Two Item Conjoint Screen was selected and a process was piloted by care teams. Quality improvement tools were used to improve the protocol.