Strengthening Community Partnerships to Support Older Adults’ Social Needs

The need for community-based approaches that address more than just medical care is paramount. A new study—co-authored by Breanne Swanson, MS, and grounded in her early work as a Primary Care Liaison—highlights how partnerships between primary care clinics and Area Agencies on Aging (AAAs) can connect older adults with essential social supports such as transportation, nutrition, housing, and social connection. These supports are crucial to overall health and the ability to age in place.

In this year-long pilot project, a primary care clinic partnered with a regional AAA to screen older patients for social determinants of health (SDOH) during annual visits and directly refer them to community-based services. Of the 385 Medicare patients screened, nearly 75% had at least one unmet social need—most often related to physical activity, financial concerns, food access, or help with daily tasks. Yet only 9% ultimately accepted a referral to the AAA, revealing a critical gap between identifying needs and ensuring that older adults receive support.

The study found real promise in building strong cross-sector relationships: the clinic, AAA, and university researchers worked closely to design a practical screening tool, integrate it into clinical workflows, and improve communication over time. But it also surfaced challenges familiar across the aging services landscape—staff turnover, inconsistent follow-up, and electronic health record systems that aren’t designed to share information smoothly with community partners.

The researchers emphasize that tackling SDOH effectively requires intentional community engagement, better awareness of aging services, and more sustainable funding for organizations like AAAs. They also point to the Cooperative Extension System (CES) as an underused partner, capable of offering health education, self-management programs, and direct connections to local resources.

Ultimately, the study makes a strong case for expanding community-clinical partnerships. By improving referrals, centering the voices of older adults, and leveraging both AAAs and CES, communities can build more equitable, coordinated systems that help older adults thrive in their homes and neighborhoods.