Beyond capacity: qualitative stakeholder perspectives on demand for health-related social needs navigation through patient self-navigation tools

Health-related social needs (HRSN) screening has attracted growing investment in recent years. Despite rising HRSN screening rates, resource referral and receipt remain low. As a result, patient self-navigation models – in which patients independently identify, contact, access, and utilize resources to address HRSN with the support of tailored written resource navigation lists – are emerging, though they remain understudied, especially outside of pediatric care. In response, this study triangulated qualitative data from three informant groups involved in HRSN navigation in a large urban ambulatory care network, to improve understanding of determinants which shape HRSN self-navigation. For this qualitative study, semi-structured interviews were conducted from October 2023 - August 2024 with community health workers (CHWs; n = 8), physicians (n = 12), and community-based organization partners (n = 12) involved in HRSN screening, referral, or service delivery. All interviews were led by a trained qualitative researcher in English and were audio-recorded and transcribed verbatim. A team of analysts thematically analyzed the data, deductively grounding codebook development and theme generation in the Consolidated Framework for Implementation Research 2.0. All groups agreed that designing self-navigation tools is important for expanding reach, while acknowledging that doing so may only support a subset of patients. Patient-level barriers to HRSN self-navigation included fear of documentation status exposure, lack of time, limited digital literacy, and language discordance, while institutional barriers included physicians’ lack of time, training, and resources for HRSN navigation, as well as community health worker and community-based organization partners’ lack of capacity. Poor self-navigation experiences may produce unintended consequences (spread of misinformation; losing patients to navigation barriers), which hinder buy-in and resource connection. In response, all groups recommended offering optional, supplemental hands-on support for patients who need it to improve self-navigation effectiveness and equity. Following the push for enhanced HRSN screening, the demand for resource navigation far exceeds capacity. In response, participants expressed interest in designing and testing patient self-navigation tools, while also recognizing limitations and potential unintended consequences. Future research is needed to design and test equity-centered self-navigation tools for large urban health system contexts.