Building Tailored Resource Guides to Address Social Risks and Advance Health Equity in the Veterans Health Administration
Background: Health care organizations, including the Veterans Health Administration (VHA), are increasingly adopting programs to address social determinants of health. As part of a comprehensive social risk screening and referral model, tailored resource guides can support efforts to address unmet social needs. However, limited guidance is available on best practices for the development of resource guides in health care settings.
Observations: This article describes the development of geographically tailored resource guides for a national VHA quality improvement initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), which aims to systematically screen for and address social needs among veterans. We outline the rationale for using resource guides as a social needs intervention and provide a pragmatic framework for resource guide development and maintenance. We offer guidance based on lessons learned from the development of ACORN resource guides, emphasizing a collaborative approach with VHA social workers and other frontline clinical staff, as well as with community-based organizations. Our how-to guide provides steps for identifying high-yield resources along with formatting considerations to maximize accessibility and usability among patients.
Conclusions: Resource guides can serve as a valuable cross-cutting component of health care organizations’ efforts to address social needs. We provide a practical approach to resource guide development that may support successful implementation within the VHA and other clinical settings.
How to BUILD RESOURCE GUIDES
Our team created resource guides (Figure) to provide veterans with concise, geographically tailored lists of VHA and other federal, state, and community services for the social risk domains included on the ACORN screener. To inform and develop a framework for building and maintaining ACORN guides, we first reviewed existing models that use this approach, including Boston Medical Center's WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) and Thrive programs. We provide an overview of our process, which can be applied to clinical settings both within and outside the VHA.18,19
Partnerships
Active collaboration with frontline clinical social workers and local social work leadership is a critical part of identifying and prioritizing quality resources. Equipped with the knowledge of the local resource landscape, social workers can provide recommendations pertaining to national or federal, state, and local programs that have a history of being responsive to patients’ expressed needs.20 VHA social workers have robust knowledge of the veteran-specific resources available at VHA medical centers and nationally, and their clinical training equips them with the expertise to provide guidance about which resources to prioritize for inclusion in the guides.20
After receiving initial guidance from clinical social workers, our team began outreach to compile detailed program information, gauge program serviceability, and build relationships with both VHA and community-based services. Aligning with programs that share a similar mission in addressing social needs has proved crucial when developing the resource guides. Beyond ensuring the accuracy of program information, regular contact provides an opportunity to address capacity and workflow concerns that may arise from increased referrals. Additionally, open lines of communication with various supportive services facilitate connections with additional organizations and resources within the area.
The value of these relationships was evident at the onset of the COVID-19 pandemic, when the ACORN resource guides in use by our clinical site partners required frequent modifications to reflect rapid changes in services (eg, closures, transition to fully virtual programs, social distancing and masking requirements). Having established connections with community organizations was essential to navigating the evolving landscape of available programs and supports.
Curating Quality Resources
ACORN currently screens for social risks in 9 domains: food, housing, utilities, transportation, education, employment, legal, social isolation/loneliness, and digital needs. Each resource guide pertains to a specific social risk domain and associated question(s) in the screener, allowing staff to quickly identify which guides a veteran may benefit from based on their screening responses. The guides are meant to be short and comprehensive but not exhaustive lists of programs and services. We limit the length of the guides to one single-sided page to provide high-yield, geographically tailored resources in an easy-to-use format. The guides should reflect the geographic area served by the VHA medical center or the community-based outpatient clinic (CBOC) where a veteran receives clinical care, but they also may include national- and state-level resources that provide services and programs to veterans.
Although there is local variation in the availability and accessibility of services across social risk domains, some domains have an abundance of resources and organizations at federal or national, state, and/or community levels. To narrow the list of resources to the highest yield programs, we developed a series of questions that serve as selection criteria to inform resource inclusion (Table).
Because the resource guides are intended to be broadly applicable to a large number of veterans, we prioritize generalizable resources over those with narrow eligibility criteria and/or services. When more intensive support is needed, social workers and other VHA clinical and nonclinical staff can supplement the resources on the guides with additional, more tailored resources that are based on individual factors, such as physical residence, income, transportation access, or household composition (eg, veteran families with children or older adults).
