“The resources are there, it’s just not sufficient:” Primary Care Team Members and Their Experiences with Connecting Patients to Needed Resources

Background: Non-medical drivers of Health (NMDOH) (e.g., discrimination, income) influence the health status of individuals and their families. In primary care, where clinicians are trained to provide continuous, comprehensive care to patients, there is increasing recognition of the complexity to treat patients impacted by adverse NMDOH. Addressing complex needs requires coordinated support from both healthcare and social systems to overcome socioeconomic barriers and improve outcomes. The purpose of this project was to identify barriers that clinic team members encounter when referring patients to resources. Methods: Focus groups were conducted with Primary Care Providers and staff (e.g., Social Workers) regularly tasked with referring patients to community organizations. Interviews were audio-recorded, transcribed, and analyzed. Results: Participants described 3 themes related to barriers: (1) PCPs Are Unaware of Appropriate Referral Processes and Services/Scope of Services Available Internally , (2) Constant Fluctuation of Community Resources Limit Access , and (3) Cost, Communication, Transportation, and Paperwork Limit Patient Access to Services . A fourth theme included participants’ recommendations for Solutions to Improve the Referral Process and Communication . Conclusion: Understanding the barriers between healthcare providers and community organizations can provide a guide toward improving referral protocols and access to resources, thus ultimately leading toward a more equitable community.