During the COVID-19 pandemic, some Community-Based Organizations (CBOs) in New York City s their services and client base due to reduced resources. Despite pandemic-related challenges, three CBOs—Health People, Korean Community Services, and the Mexican Coalition for the Empowerment of Youth and Families—continued to offer the National Diabetes Prevention Program (NDPP), which empowers people with pre-diabetes to reduce their diabetes risk through lifestyle change. In partnership with NYC REACH, these three CBOs enhanced the program by adding screening and referral for health-related social needs (HRSN), which are not part of the official NDPP curriculum. 

NYC REACH evaluated the program, finding that HRSN screening and referral helped NDPP participants access community resources and meet needs that impact their health.   

• How did HRSN screening and referral benefit participants? The intervention decreased food insecurity, addressed clients’ need for assistance with benefits applications (Figure 1), and increased access to health insurance. 
• How did using an online platform for screening and referral help CBOs succeed?   Using an online community resource referral platform (NowPow, since bought by Unite Us) allowed CBOs to: (1) efficiently find and connect clients to a variety of social service providers, (2)  provide current information about resources to clients without continually updating paper-based handouts, (3) search for resources by zip code, and (4) enable staff to learn new skills which increased their capacity to meet clients’ needs.  

Keep reading to learn more about the program and its impact. 

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The Partnership:

Health People, Korean Community Services, and the Mexican Coalition for the Empowerment of Youth and Families partnered with NYC REACH in 2020 to implement the program. 

The Program: HRSN screening for NDPP participants. 

• Screening: NDPP lifestyle coaches screened clients twice, several months apart, using a 33-item survey adapted from two validated tools: (1) PRAPARE and (2) the Accountable Health Communities Health-Related Social Needs Screening tool.  
• Referral: Coaches used a community resource referral platform provided by NYC REACH to generate a customized list of social service organizations for each participant.   
• A community resource referral platform is an online directory of social service providers that helps providers and CBOs refer clients to resources based on location and need.  
• Examples of currently available resource referral platforms include UniteUs and FindHelp.  

The Evaluation: Evaluators aimed to answer two questions.

1. Were clients’ social needs resolved? NYC REACH evaluators compared social needs that participants reported at the start of the NDPP program with those reported at the second screening. A need was considered “resolved” if the participant reported it at the first, but not the second screening. 
2. What are the benefits and challenges of implementing social needs screening? Evaluators interviewed seven staff members from the three CBOs to gain a deeper understanding. 

Who participated in the evaluation? 

Forty-three out of 59 NDPP participants were screened twice. Of the 43 participants: 

• Most identified as women (77%) 
• More than three-quarters were 45 years or older 
• All identified as members of minoritized racial or ethnic groups, predominantly Asian (54%) or Latino (37%)   

How did screening and referral impact clients’ social needs?  

HRSN screening and referral may have helped meet some of the clients’ social needs, NYC REACH’s evaluation suggests.  Between the first and follow-up screenings, clients’ reports of: 

• Food insecurity dropped from 23% to 10% 
• Needing help applying for food benefits (e.g., SNAP) fell from 41% to 15% 
• Needing help applying for cash assistance declined from 31% to 20% 
• Having health insurance grew from 69% to 83% 

What were the benefits of screening and referral, according to CBO staff? 

HRSN screening allowed CBOs to get a well-rounded picture of each person’s needs, including supports that might enhance their health. The screening process often revealed needs that a client may not have otherwise volunteered. 

• “It’s been an opportunity to identify all the participants’ needs. They often come to us with what they think is one [need]… but in the process of the interview, we get a clearer picture of what additional supports they might benefit from. This is very important because someone may come to us for information about improving their health, and based on their answers to the questions, we can identify the supports they need for [other] things that might be impacting their health.”  

As intended, screening and referral facilitated linkages to community resources such as public benefits and food pantries. Each CBO recalled NDPP participants being connected to these types of assistance. 

• “Using the screening as part of the NDPP program helps to connect them to other services. We connected some participants to SNAP, some to nutritional counseling, others… to the emotional support program at our agency. Some participants were also referred to food pantries.”  

The resource referral platform streamlined the process of identifying community resources. It eliminated the need for staff to continually update the paper-based resource handouts that they had previously used. 

• “The NowPow [online social needs platform] system is easy because you can use the zip code to find services.” 
• “Resource sheets that we have… have to get updated all the time. You have to call all these numbers to see if the resources are current. It’s nice that NowPow is updated.” 

Learning to use a social referral platform strengthened staff competency in service navigation and their capacity to efficiently meet a broader spectrum of client needs. 

• “[Using a resource platform] has had a great impact. NowPow is an easy system to utilize. Staff found it helpful and are feeling more confident in their role.”  

What challenges did CBO staff experience? 

Lifestyle coaches reported that the screening survey was too long and that some clients were uncomfortable answering income and social benefits questions. Undocumented clients were particularly concerned about privacy. 

The COVID-19 pandemic also posed a barrier to implementation. Many resource providers were closed or offered limited services, and some never responded to participants’ calls. Separately, some participants experienced language barriers when accessing services because organizations did not speak Korean.