Beyond Care Coordination: Strengthening Community-Governed Social Care Integration in Primary Care—Implications from a Rural Midwestern Model for Low- and Middle-Income Health Systems

Abstract

Savitz et al evaluated a Health Equity Coordinator (HEC) model designed to strengthen collaboration between primary care practices and community-based organizations to address patients’ social drivers of health (SDoH). 1 The intervention demonstrated substantial engagement with patients and community partners while showing reductions in unmet social needs and missed appointments within the intervention clinic. However, no statistically significant differences were observed in SDoH resolution or healthcare utilization compared with comparator clinics, leading the authors to conclude that longer follow-up may be required to demonstrate measurable effects. 1 Their study represents an important contribution to the growing evidence supporting the integration of social care into primary healthcare. The findings also highlight a broader implementation challenge. Establishing referral pathways and appointing dedicated care coordinators are necessary steps, but they may not be sufficient to improve outcomes if community organizations lack the resources, workforce, or infrastructure needed to respond effectively. Recent literature on integrated care and social prescribing suggests that health systems have become increasingly proficient at identifying social needs while community capacity to address those needs often remains limited. 2,3 Consequently, referral volume alone should not be interpreted as a measure of implementation success. Future evaluations of similar models may therefore benefit from incorporating implementation outcomes beyond healthcare utilization. Measures such as referral completion, bidirectional communication between healthcare providers and community organizations, implementation fidelity, community readiness, and patient-reported experience could provide a more comprehensive understanding of intervention effectiveness. Implementation science frameworks, including RE-AIM and the Consolidated Framework for Implementation Research, offer useful approaches for identifying contextual factors that influence the sustainability and scalability of multisector interventions. 4 These considerations are particularly relevant for low-and middle-income countries such as the Philippines. The implementation of the Universal Health Care Act has accelerated efforts to strengthen primary care networks while recognizing the importance of addressing social determinants of health. However, social services