Evidence map›Paper›PMID 40266648›Full record

ArticleMedical care2025

The Impact of a Bidirectional Clinic to Community Social Care Referral Program.

Shari D Bolen, Jonathan Lever, Chris Mundorf, Alvonta Jenkins, Rachel Waitzman, Samantha Smith, Matthew Finley, Joseph Daprano, Eva Johnson, Marie Masotya and 9 more

Abstract read
In one paragraph

Article in Medical care, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Digital social prescribing: a concept analysis.Frontiers in public health · 2026
    Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

19 authors.

Shari D BolenDepartment of Medicine, The MetroHealth System and Case Western Reserve University, Cleveland, OH.ORCID 0000-0003-1469-8203
Jonathan LeverBetter Health Partnership, Better Health Partnership, Cleveland, OH.
Chris MundorfBetter Health Partnership, Better Health Partnership, Cleveland, OH.
Alvonta JenkinsBetter Health Partnership, Better Health Partnership, Cleveland, OH.
Rachel WaitzmanDepartment of Medicine, Case Western Reserve University, Cleveland, OH.
Samantha SmithDepartment of Epidemiology, Surveillance, & Informatics, Cuyahoga County Board of Health, Parma, OH.
Matthew FinleyUnited Way of Greater Cleveland, Cleveland, OH.
Joseph DapranoDepartment of Internal Medicine/Pediatrics, The MetroHealth System and Case Western Reserve University, Cleveland, OH.
Eva JohnsonDepartment of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH.
Marie MasotyaPediatrics, University Hospitals, Cleveland, OH.
Shivani JoshiPediatrics, University Hospitals, Cleveland, OH.
Anandhi GunderDepartment of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH.
Melissa E LohrDepartment of Pediatrics and Informatics, The MetroHealth System/CWRU, Cleveland, OH.
David Bar-ShainDepartment of Pediatrics and Informatics, The MetroHealth System/CWRU, Cleveland, OH.
David C KaelberDepartment of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH.
Tatyana KhaledDepartment of Epidemiology, Surveillance, & Informatics, Cuyahoga County Board of Health, Parma, OH.
Dieter SumerauerPediatrics, University Hospitals, Cleveland, OH.
Heidi GulletCenter for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH.
Kurt C StangeCenter for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH.

Funding

NCCDPHP CDC HHS U01 DP006586NCCDPHP CDC HHS U58 DP005851The Cleveland Foundation NAUnited Way of Greater Cleveland NA
6 · The paper itself

Abstract

backgroundPractical knowledge of how to address patients' social needs could have a large health impact.

objectiveDescribe a scalable electronic health record (EHR)-facilitated, clinic-to-community linkage (CCL) program that addresses social needs at 6 clinics in 4 health systems. RESEARCH

designPrimary care teams referred eligible patients to United Way 211 (UW 211) via a point-of-care EHR referral between 2018 and 2023. Patients were eligible if they were adults with uncontrolled blood pressure or blood sugar or 2-17 years old with overweight/obesity or asthma. UW 211 referred patients to assess and connect them with community resources and provided electronic feedback to the EHR. We conducted descriptive analyses of process measures (eg, patients referred, needs identified, need resolution). We then conducted pre-post analyses of selected health outcomes (ie, blood pressure, weight, and asthma exacerbations) versus comparison clinics.

resultsReferral ranges varied by clinic from 3% to 43%, with 1224 total patients referred and 38% (n=461) reached by UW 211. All 461 had at least one need, and 87% (n=400) had one need resolved or a resolution in progress. Reached patients had an average of 2.9 (SD 1.3) needs and an average of 10.1 resource referrals provided (SD 6.1). Top needs included food, physical activity, housing and utilities. No differences were found pre to post within the intervention clinics except for improvements in blood pressure control. However, comparison clinics had greater improvements in blood pressure control during the same time frame.

conclusionsAn EHR-facilitated, closed-loop CCL program to address patients' social needs is feasible. Further research on the comparative effectiveness and sustainability of models to address social needs will be critical in advancing health equity.

Indexed as

Community Health ServicesPrimary Health CareReferral and ConsultationAdolescentAdultAgedAsthmaChildChild, PreschoolElectronic Health RecordsFemaleHumansMaleMiddle Agedprimary carequality improvementsocial determinants of health

Identifiers

PMID40266648
PMCPMC13505879

What OpenQuestion holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.