Healthcare system leaders are increasingly aware of the impact of health related social needs (HRSNs) and are now integrating social care into the delivery of healthcare to address these needs. This integration is complex, requiring intentional engagement of healthcare staff, patients, and community organizations. The Institute for Healthcare Improvement, with funding from Pfizer, supported a 15-month quality improvement (QI) Learning and Action Network (LAN) with three integrated delivery networks (IDNs) from across the United States that were early in the process of integrating social care into their healthcare systems. During the LAN, the IDNs used QI methods to identify and test social care integration strategies with their patient populations. Teams shared their results with one another and stakeholders in their own systems to enhance the rate of learning and improvement. At the core of this work was a robust process to understand the needs and assets of patients in order to define aims and guide the design of effective, equitable, and sustainable care.

Two of these IDNs will present their experiences and approaches to improve social care integration. Legacy Health, serving Oregon and Washington, tested strategies to identify and address food insecurity and increased the number of primary care sites screening for this need from 11 to 25. Northern Light Health, serving Maine, tested approaches to increase screening rates for 11 HRSNs during the primary care intake process and achieved a 277% increase in screening rates in five practices. Practical advice and lessons learned from the LAN will be shared.