Virtual addressing reality: Development of a virtual social work program to address health-related social needs.
Authors: Weber Dana , Eigege Chinyere , Pearcy Emily , Neeb Jessica louise , Staggs Stuart George , Jameson Melissa 
Published: September 2024

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Background:
Assessment of Health-Related Social Needs (HRSNs) has become an integral part of understanding barriers to care and improving patients’ lives and experiences as they receive cancer care. Increased assessment, however, can result in a raised awareness of unmet needs in oncology patient populations. This tends to highlight gaps in services and necessitate additional staff to attend to these needs. Addressing HRSNs can be facilitated with lay navigators (non-licensed staff), licensed staff, clinical staff, and other members of a multi-disciplinary team. Actions can include, but are not limited to, identification of practical concerns, referrals to community-based organizations (CBOs), referral to the clinical team, or further escalation to a licensed clinical social worker (LCSW).
Methods:
The National Comprehensive Cancer Network (NCCN) Distress Thermometer screening tool was implemented in July 2023 where patients are screened every 3 months in a community oncology setting. A workflow was established where a clinic staff would administer the screening tool and enter the details of the screening into the EHR system. Based on established criteria, the patient would be referred to the social work team via electronic referral. Due to an increase in screening and subsequent referrals, a virtual team of (5) social workers called Patient Resource Coordinators (PRCs) was established in December 2023 to address the practical concerns and facilitate the coordination of resources based on identified needs. After the team was established, non-urgent referrals were then assigned to a PRC. The PRC could refer to an on-site LMSW/LCSW for higher level of acuity assessment, like crisis support or positive PHQ-9 scores.
Results:
See Table.
Conclusions:
The virtual PRC team is able to manage ~55% of referrals made to a social worker based on results from an HRSN screening tool. This has allowed the onsite LMSWs/LCSWs to work at the top of their license and enabled patients to receive support with care coordination and connection to resources. Over time, the referrals managed by the virtual team has increased and their connections to patients have grown. In the future, the PRC team aims to add additional LCSW services to assist patients with higher acuity needs. This will broaden the scope of services available to the patients to address their health-related social needs in a timely manner.

PRC Activity
Dec ’23
Jan ‘24
Feb ‘24
Mar ’24
Apr ‘24
May ’24 (*May to date at time of submission)

# of Referrals Received via EHR
110
542
610
586
1216
570

# of Referrals Assigned to PRC
45
245
299
315
660
312

% of Referrals Assigned to PRC
41%
45%
49%
54%
54%
55%

*Secondary Referral to SW

8
9
20
4

# of calls attempted
102
479
536
577
959
448

# of patients reached
38
180
217
270
413
277

% of patients reached
37%
38%
40%
47%
43%
62%

# of practical concerns identified
31
131
426
430
742
349

Total Visit Duration (in hrs.)
36hrs
181hrs
348hrs
450hrs
836hrs
485hrs