From Screening to Referral: Connecting Heart Transplant Patients With Resources to Meet Social Needs Remains Challenging Despite Adequate Support

Background Screening for social needs has become increasingly common across healthcare settings. While pediatric programs across the United States have successfully implemented social needs in a clinic setting, the ability to connect families with a positive screen to needed resources is not entirely clear. Through this quality improvement initiative, we sought to universally screen for social needs and refer all families with a positive screen to community resources. Methods Social needs screening was conducted within a pediatric heart transplant clinic in the Western USA. The clinic team devised two separate resource referral pathways: high‐risk needs (addressed by social worker) and low‐risk needs (referred to Unite Us). Referral outcomes of interest were resource identification and resource connection, with the social worker pathway demonstrating higher effectiveness. Results Social needs screening identified 66 active needs among 28 of the 86 families screened. Team members were unable to identify a community resource for almost half of the identified needs ( n = 30, 44.8%), most often because a resource was not found ( n = 23). Of the 59 needs addressed, the clinic team was able to connect families to resources for 24 needs. Overall, families were connected to resources for 36.4% of all identified needs. Conclusions Screening for social needs revealed a high degree of social need. However, referral to resources was hampered by two key barriers—lack of available resources and lack of local program follow‐up. When resources were identified, the in‐person support and referral pathway was more effective than remote support.