Barriers and Facilitators to Managing Social Care in the Digital Era Among Michigan Health Centers

Within the health care system, screening for social risks and responding to patients' social needs (eg, food, housing, and employment) are growing priorities.1 Information technology (IT) is increasingly being used to document social needs2 and coordinate services often outside of traditional medical care. Federal agencies and researchers are examining new payment and care models used to meet health-related social needs.5 Investigations of population health initiatives led by public and private payers are also demonstrating the efficacy of using IT to screen for social risks, refer patients to community services, and identify health plan superutilizers by accounting for different social factors.6,7 However, studies systematically examining the local infrastructure and data activities that have emerged are needed. Investigators drew on sociotechnical theory to reveal the human/organizational and technological elements of the local information infrastructure and care management activities developed in Michigan communities.12,13 A sociotechnical systems model was used to categorize community priorities, IT adopted, and workforce developed to manage social care and address quality.14 Results were presented to answer these research questions: (1) What are the facilitators of participating in community-wide activities to deliver high-quality care? and (2) What are the barriers to meeting patient social care needs in communities? METHODS This is a qualitative study of community-wide activities and resources used to deliver social care. RAP is an intensive, team-based qualitative inquiryusing data triangulation, iterative analysis, and additional data collection to quickly develop an understanding of a situation, setting, or phenomenon from an insider's perspective.16 RAP is a demonstrated and efficient method for time-sensitive health services research used in evaluations of applied clinical informatics across settings (eg, hospitals, primary care).17 The data extraction template tool was tested by the investigators for consistency and reliability before transcript coding commenced.