SUN-853 - Integration of Student-Led Social Care Navigation into Endocrinology Clinics to Address Social Determinants of Health

Background: Unmet social needs, including food insecurity and barriers to public benefits, are major drivers of poor outcomes in patients with endocrine diseases such as diabetes and obesity. Social instability undermines medication adherence, nutritional management, appointment attendance, and continuity of care, contributing to poor glycemic control and persistent health disparities. Despite growing recognition of the importance of social care integration, many outpatient clinics lack scalable, workflow-integrated infrastructure to identify and track social needs during routine care.

Methods: We implemented a student-led social care navigation program embedded within the outpatient Duke Endocrinology Clinic in Durham, North Carolina. Undergraduate volunteers were trained in motivational interviewing, health systems navigation, and standardized social needs workflows. Students utilized NCCARE360, a statewide electronic social referral platform enabling referral tracking, documentation, and case resolution. We conducted a retrospective analysis of patients supported between February 1, 2023 and October 29, 2025.

Results: During the study period, 477 patients (mean age 53.8 ± 16.8 years; 59.2% female; 45.8% African American) were supported, generating 1,027 referrals across multiple social need domains. The most frequently identified needs included benefits eligibility screening (45.2%), access to food pantries (9.5%), and emergency food assistance (8.9%). Among community-based referrals, 30.4% were accepted, while others were rejected (28.0%), completed off-platform (19.6%), auto-recalled or recalled, or remained in intermediate workflow states. At the patient level, 112 of 477 patients (23.5%) had at least one external referral accepted.

Among referrals that progressed to cases, resolution rates varied by service domain. Food assistance cases had the highest proportion resolved (42.7%). Resolution rates were also notable for benefits navigation (37.5%) and clothing and household goods (41.2%), but lower for utilities (1.9%), transportation (4.5%), and physical health services (12.9%). Across domains, unresolved or open cases commonly reflected inability to contact clients, service unavailability, or ineligibility.

Conclusions: Embedding a student-led social care navigation program within endocrinology clinics enabled systematic identification, referral, and case-level resolution of social needs using a statewide electronic platform. Despite substantial attrition, meaningful proportions of patients obtained services, highlighting the value of integrating social care into routine endocrine practice. This model offers a scalable, policy-aligned approach to expanding clinic capacity while providing experiential education in health equity and systems-based care.

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