Dietitians as Boundary Spanners: A Case Study of a Cross-Sector Health-Related Social Needs Program
Top Things to Know
Dietitians can play a critical implementation role in Food Is Medicine programs by bridging healthcare and community systems, translating clinical recommendations into real-world nutrition supports, and coordinating care across sectors.
Flexible program structures that empower frontline staff may strengthen implementation by enabling adaptive problem-solving, cross-sector learning, and patient-centered service delivery.
As Food Is Medicine initiatives scale, workforce development may need to extend beyond clinical nutrition competencies to include systems thinking, relationship management, communication, and cross-sector coordination skills.
Summary of Conclusion/Findings
This qualitative case study explored how nine registered dietitians working within a Massachusetts Medicaid Health-Related Social Needs (HRSN) nutrition program helped integrate medical and social care across community-based organizations and a Medicaid Accountable Care Organization (ACO). Dietitians described implementation as a dynamic, iterative process in which workflows, referral pathways, and communication practices were continuously refined through feedback and collaboration rather than following a fixed implementation plan. Participants reported serving as “boundary spanners,” translating clinical nutrition recommendations into practical, culturally relevant supports while coordinating across healthcare, community organizations, and patient settings. Cross-sector collaboration expanded dietitians’ professional roles and strengthened skills in communication, relationship building, advocacy, and problem-solving, particularly when navigating challenges such as incomplete clinical information and fragmented information systems. Dietitians also reported that the program’s flexible, shared-governance structure increased their professional agency, allowing them to tailor services and address patients’ social and medical needs more holistically.