Abstract
OBJECTIVE: High rates of unmet health-related social needs (HRSNs) have been reported among hospitalized children. Community health workers (CHWs) embedded within health systems can assist families with unmet HRSNs. This study evaluated an inpatient HRSNs screening, referral, and CHW resource navigation intervention in a hospital in Bronx County, New York. METHODS: We conducted a retrospective study of hospitalized families between December 2023 and November 2024. Patients were screened for HRSNs upon admission and referred to CHWs after self-reporting unmet HRSNs and confirming they wanted help. We evaluated the intervention using descriptive statistics and periodic reflections analysis following the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) implementation framework. RESULTS: Of 5350 admitted patients, 3291 (61.6%) were screened for HRSNs with 986 (30.0%) screened patients reporting unmet HRSNs. Of the admitted patients, 670 (12.5%) were referred to CHWs and 491 (73.3% of those referred) accepted CHW navigation. Of the CHW navigated patients, 484 (98.6%) were either connected or equipped to connect to social services. Of patients connected to services, 183 (96.8%) self-reported that their HRSNs were improved or resolved. The estimated annual cost of the intervention was $180.63 (IQR $154.58-$180.63) per patient connected with CHWs. Periodic reflections analysis identified facilitators and barriers to adoption. CONCLUSIONS: Most hospitalized families were screened and those with unmet HRSNs were appropriately referred to CHWs. CHWs were successful in helping families connect to social services, leading to improved or resolved HRSNs. Future research should evaluate the impact of CHW support for unmet HRSNs on child health and health care utilization.