P3.P314: The Connector Service: High Intensity Care Management to Address Medical and Social Needs

Background: Social determinants of health, defined by Healthy People 2030 as” the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” are incredibly impactful on health and wellbeing. Children with medical complexity and their families are particularly susceptible to the impacts of unmet social needs. In addition to higher healthcare utilization, the literature describes higher rates of poverty, food and housing instability, economic risk, and more. In response to these concerns, Primary Children’s Hospital developed an intensive care management program to partner with families to address social determinants of health and care access issues via hands-on assistance with resources, intensive medical and social care management, and patient education.

Methods: Patients living within Salt Lake County with high medical complexity (3 or more body systems) facing barriers of ineffective navigation of complex healthcare system were eligible for enrollment. Utilizing a home-based high-intensity care management model, team members administered the Connect2Health or other validated social needs screening tools upon team enrollment to evaluate for social needs affecting child and family health and wellbeing. Over the course of enrollment, team members worked to address social determinants of health through hands-on assistance with local accessible resources to address social needs while being inclusive of the family’s abilities, culture and language, and dynamics. In addition to addressing social needs, the team worked to create points of contact for families within the community and medical system to maximize outpatient support and thus avoid unnecessary hospital utilization.

Results: Over the life of the program, over 150 patients have been enrolled in our services, with an average active census of 28 patients. At any time, census consisted of a range of 25-48% non-English preferring patients. The most common social needs reported by families were clothing, living space, and ability to pay bills. Data evaluating race, ethnicity, gender, insurance status, and Child Opportunity Index are currently being evaluated with data forthcoming by July 2024. Furthermore, data collected over the course of the program has shown an average 52% reduction in hospital admissions and a steady reduction in ED visits (a nearly 30% decrease) when comparing pre- and post-enrollment data.

Conclusion: The Connector Service Program demonstrates the value of high intensity care management to address social needs and provide medical support to patients and families most marginalized by medical and social systems. By connecting families with community resources and families with medical systems, we can empower families to overcome barriers and navigate challenging and inequitable systems while helping medically complex children to grow and thrive in their homes.