Addressing Social Needs to Improve Health in Adults with Multiple Chronic Conditions

Adults with multiple chronic conditions account for the majority of health expenditures in the US. The added challenges of social-related barriers to care (e.g., transportation, food, housing, digital access, financial stresses) have been associated with worse disease outcomes and decreased life expectancy. This study will compare two strategies for addressing identified social needs: 1) intensive (phone-based ongoing outreach from a health navigator) vs 2) light touch (tailored outreach with educational materials, referral to phone/website). We will also interview patients and providers to identify barriers and facilitators at each step in the pathway, as well as examine heterogeneity of treatment effects.

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