Addressing social and health needs in health care: Characterizing case managers' work to address patient‐defined goals

Abstract Objective To test quantitative process measures characterizing the work of social needs case managers as they assisted patients with diverse health‐related needs—spanning both medical and social domains. Study Setting and Design The study analyzed secondary data on 7076 patients working with 147 case managers from the CommunityConnect social needs case management program in Contra Costa County, California from 2018 to 2021. The service—designed to be holistic with a focus on social determinants as root causes of health issues—helped patients navigate social services, health care, and mental health care. Data Sources and Analytic Sample We used cross‐sectional analyses to quantitatively characterize electronic health records (EHRs) derived measures of case management intensity (goal updates), duration (days goal was open), and outcomes for 19 different categories of health and social goals. Mixed‐effects regression models were used to examine how work process measures varied according to goal categories. Models nested goals within patients within case managers and adjusted for patient‐level covariates. Principal Findings The most common goals were dental care (53%), food (40%), and housing (39%). In adjusted analyses, housing goals had significantly more case manager updates than any other type of goal with a marginal mean of 14.0 updates (95% CI: 13.4–14.7), were worked on for significantly longer (marginal mean of 417 days, 95% CI: 360–474) than any goal except dental care, and were least likely to be resolved. Utilities, insurance, and medication coordination goals were most likely to be resolved. Conclusions Case managers and patients repeatedly worked on goals over many months. Meeting housing needs and accessing dental care were issues that were not easily resolved and required extensive follow‐up. One‐time referral interventions may need follow‐up systems to meaningfully support social and health needs.