Addressing the social determinants of health (SDOH) is a critical step in reducing health disparities. The World Health Organization defines the social determinants of health as “the conditions in which people are born, grow, live, work and age” [1]. Specifically, examples of SDOH include housing status; food security; economic stability; education; neighborhood and physical environment; and community and social context [2]. SDOH and related health behaviors account for 80 to 90 percent of modifiable contributors to population health outcomes, while healthcare alone only accounts for 10 to 20 percent [3]. While health care alone is a relatively modest contributor to health, the United States spends nearly 20% of its gross domestic product on medical care compared with only 16% on social care, and achieves poorer health outcomes than peer countries [4]. This allocation of resources persists despite recent evidence that addressing individual social needs can improve health outcomes and expenditures [56789].

In addition to limitations on financing social care, the systems of health and social care remain siloed. Research of care models integrating medical and social care demonstrate improvements in patients’ access to social services, patient satisfaction, health behavior, and healthcare utilization [71011121314]. Achieving these outcomes requires a shift from the traditional biomedical model of health to establish closer collaborations with non-medical sectors in support of overall health and well-being. To implement person-centered integrated care models that aim to coordinate services across both health and social services, healthcare providers can start with a screening process for unmet social needs that enables targeted referrals to community or public government programs [15]. Research has demonstrated the feasibility of screening for unmet social needs as part of routine primary care visits [16171819]. There has been progress towards identifying strategies and workflows to integrate social needs screening and referral programs [2021222324] based on a vision for organizing care that recognizes the importance of ‘moving upstream’ to promote health equity [2526]. However, there is a lack of evidence describing the effectiveness of referring patients to community resources and the extent to which patients are able to access identified community resources [710].

Health systems often do not have the capacity to both screen for and respond to unmet social needs through follow up and ongoing case management [27]. One potential emerging solution to build capacity for integrated care is utilizing volunteers [2829]. Volunteers are a low-cost and underutilized resource that health systems can leverage to help address patients’ unmet social needs while educating tomorrow’s workforce [10]. In a student volunteer based model, students can interact with patients to screen patients’ needs, refer them to community-based organizations, or provide short-term follow-up to motivate follow-through and problem solve barriers [3031323334]. Evidence has shown that volunteers can help address patients’ routine social needs and allow clinic social workers and case managers to work at the top of their license, such as providing substance abuse and mental health treatment for higher-risk patients [30323334].

Volunteer models are typically adopted by larger health systems with resources to manage volunteer recruitment, training and oversight. However, safety-net community health centers, that serve uninsured and underserved individuals regardless of ability to pay, often lack resourced volunteer service programs yet are at the forefront of serving patients with unmet social needs and face greater resource constraints [35]. In our program pilot, we explored how student volunteers could support efforts to social needs screening, referral, and follow-up to improve integrated health and social care in a federally qualified health center. This integrated care case study is on our “Student Help Desk” model implemented at the Lincoln Community Health Center in Durham, North Carolina in partnership with Duke University. The aim of this case study is to provide a description of the process and practical considerations to implement a student volunteer “community resource navigator” model to address patients’ social needs.

We conducted a two-month pilot of our community health center Help Desk model. This included a two-week screening and referral period, followed by six weeks of follow-up calls in the pilot period. Of the 61 patients screened for unmet social needs by the behavioral health case managers, 29 patients were referred to four Help Desk student volunteers for follow-up (Figure 3). Patients not referred (N = 32) constituted those without at least one community resource referral, those who refused to be contacted after the clinic visit, those with needs that student volunteers were not trained to manage (i.e. active domestic violence, severe mental health challenges), those who did not speak English or Spanish, or had missing contact information. Help Desk volunteers reached 26 patients (89%) by phone at least once within six weeks after their initial screening. Most (65%) of the patients reached were called on the first call attempt.

Of patients referred to services, the three most frequent unmet social needs were related to medical care (e.g. access to affordable medications or specialty care), food insecurity, and financial assistance. Eighty-three percent of patients had referrals to community and social services for at least one of these top three referral areas. Fourteen patients (48%) reported accessing at least one of the recommended community resources. Barriers for patients unable to connect to the resources recommended included lack of time, lost contact information, need to clarify service application process, compromised physical health, major life events that took precedence, and failed contact with community-based organizations.

Out of the 26 patients reached by volunteers, only seven patient cases were escalated for additional input or action from the behavioral health case manager. In the majority of these seven cases, the case manager was included primarily to encourage or reinforce the importance of the community resource referral. None of the patients presented with an emergency during follow-up that student community resource navigators needed to immediately escalate.

Social needs and related health behaviors are major drivers of health outcomes [3]. Federally qualified health centers care for some of the most vulnerable people in the United States yet often lack the capacity to fully support and coordinate their patients’ follow-through care. In this descriptive case study, we outline our structured process for planning and implementing a student volunteer program to help patients navigate community resources for their social needs. Our efforts underscore key considerations that may help other organizations develop academic-community partnerships to support integrated health and social care.

We found the following principles to be integral to successful implementation and program feasibility: 1) multi-sectoral collaboration; 2) well-defined scope of practice; 3) data systems to produce timely and actionable reports; and, 4) mechanisms for sustainability including training and onboarding, supervision, case conferences, and quality improvement.

Multi-sectoral collaboration was integral to building this student volunteer Help Desk for the community health center. Research and design was led by a team of Duke University students and their faculty mentors through a university-sponsored program to encourage interdisciplinary research and program implementation. While other student models were completely designed by research and clinical staff [313234], the planning process for this program, (e.g. creation on program materials, CBO directory creation, and database) was driven by students as part of a for-credit course. Following an academic course schedule with clear, graded deadlines helped keep the project planning on-track and created a culture of accountability. Unlike large academic medical centers, community health centers may not have the resources to develop and sustain a volunteer program on their own. Nonetheless, although this university-affiliated team led the intervention adaptation and refinement, they relied heavily on partnership and co-design with Lincoln Community Health Center leadership. Future evolutions of this model will need to both expand on Lincoln’s existing relationships with community-based organizations and consider state-level efforts to address social determinants of health [49]. For example, processes will need to be developed for integrating with the statewide community resource platform designed to improve coordination and communication between health and human services [50]. Similarly, future research should evaluate the cost and cost-effectiveness of this model to inform its scale as a population health strategy.

The volunteer’s scope of practice was context specific and developed through multiple iterations of stakeholder feedback. Translation to other clinics will require local evaluation of workflow in order to achieve the similar success. Our project team designed a community resource navigator role that freed up behavioral health case managers to pursue other responsibilities and maximize volunteer impact. Compared to other Help Desk models in which volunteers conduct SDOH screening and referrals [32333440], our program’s volunteers focused exclusively on follow-up. Such an approach aimed to lower the risk of the pilot by simplifying volunteer responsibilities, and thus increase program feasibility. In settings with other provider models or universal self-screening, continuity with student volunteers may require new workflows. There may be benefit in comparing the scope of practice for the student’s community resource navigator role with that of other navigators—peer navigators, community health workers, link workers—in order to establish a workforce model for wide-scale implementation [1523].

One of the largest challenges in implementing this model was designing secure and actionable data systems. Risk compliance made it impossible for volunteers to work within the community health center’s electronic health record system resulting in double data entry of the data obtained using PRAPARE screenings. Generating reports to track progress and identify areas for improvement required access to the electronic health record to compare social needs information with health data not captured in PRAPARE (e.g., health status, comorbidities, etc.). In the future, this could be improved by enabling electronic data capture of the initial social needs screen that automatically populates both the health record and the student volunteer’s data privacy compliant database.

Building sustainability beyond the pilot primarily centered on the student workforce. Recruitment, onboarding and training had to commence during the pilot period in order for the volunteer program to be resourced appropriately for the summer months when students often leave the area. Strategies to address turnover beyond the academic year transitions included creating clear expectations for volunteer commitment and having at least one clinical champion and one volunteer coordinator to ensure continuous Help Desk operations through holidays and academic calendar breaks. The investment of university resources including faculty mentors, student project leads, space and resources for volunteers and their training were essential. A weekly seminar course to teach on topics of social determinants, health service delivery, evaluation, quality improvement, and health policy complemented the efforts and contributed to the students’ learning and engagement.

Our pilot data also support the feasibility of integrating student volunteers as community resource navigators, according our feasibility measures of rate of patient refusal for follow-up, rates of patient contact via phone, and rate of escalation of patients to case managers. Only 21% of patients screened refused to be contacted by student volunteers after the clinic visit, and 89% of referred patients responded to student call attempts and voicemails on follow-up. Such data suggests that patients are open to follow-up calls from volunteers and can be consistently reached via phone. Further, the majority of patient interactions could be resolved by the student volunteers directly. Student volunteers reconnected 27% of patients with their case managers for additional support, and case managers reported this referral stream as acceptable and not burdensome. Of the patients reached by student volunteers, no emergency escalation was needed. This indicates that patients’ needs fell within the scope of practice of the navigators and limited the need for additional clinical resources due to escalation.

After the pilot program, clinic leadership, case managers, the student team, and faculty advisors agreed the student Help Desk program was feasible and committed to sustain the program at the community health center. Case managers felt that the Help Desk program did not significantly burden their workload and allowed for follow-up that the clinic could not otherwise provide. Clinic leadership was motivated to collect more follow-up patient data to assess the effectiveness and cost-effectiveness of SDOH screening and referrals in order to better inform decisions related to long-term investments in the program and potential expansion to satellite clinics. Students and faculty advisors felt the experience would be a worthwhile experience for future students, and received funding from the university to continue to scale the program operations and conduct further evaluations.

Between the pilot in spring 2019 and fall 2020, 19 additional student volunteers have been recruited and trained as community resource navigators. These students included medical students, nursing students, and undergraduate students from social science, public policy, pre-dental, and pre-health backgrounds. Since the pilot program, over 1900 patients have been screened for social needs and over 500 patients have been reached for follow-up by Help Desk volunteers. While our pilot study focused on feasibility, our team’s future analyses will focus on workforce development, implementation, and effectiveness.

The Help Desk student volunteer model for community health centers is a valuable addition to the healthcare system and to society because it provides young adults interested in health careers with firsthand exposure to social determinants of health, collaborative evaluation, and problem solving. By design, our model included interdisciplinary and interprofessional engagement of students in different levels of learning (undergraduate and graduate) and fields of study related to healthcare. Our training protocol incorporated experiential, project-based learning and community engagement to expose students to the connection between unmet social needs and health. Our Help Desk model contributes to the growing body of research on educating students in social determinants, population health, and implementation science [515253].

Due to limited staff and resources, federally qualified health centers staff often feel challenged to respond to positive social needs screens, track outcomes of past referrals, and keep resource lists up to date [18]. Previous studies have explored the feasibility of screening for unmet social needs in the community health center setting [192754], but have lacked discussion as to how community providers might build this capacity to conduct screening and follow-up.

In our case study, we describe in detail a structured process in which university students and their advisors were able to partner with a community health center to launch volunteer resource navigator programs. Specifically, we highlight key steps in our planning and implementation steps, such as studying similar models through literature review and observation, developing a resource directory, and evaluating the center’s patient population, clinical workflows, and data infrastructure. We also highlight four principles key to program feasibility. Our pilot data further reinforces the feasibility and sustainability of this model. We recommend that community health centers in areas with institutions of higher education consider these academic-community collaborations to increase capacity to serve patients’ needs and provide patient-centered care beyond individual clinic appointments. Trained student volunteers are an untapped resource that provide a low-cost and high-yield solution and can improve integrated care.