From Mandate to Meaning: A Health Equity Implementation Framework and Knowledge-to-Action-Informed Qualitative Study of Health-Related Social Needs Implementation

Abstract

Background:

Health-related social needs (HRSNs), including food insecurity, housing instability, transportation barriers, and financial strain, are increasingly recognized as critical to patient-centered care. Despite growing mandates and incentives to integrate HRSN screening and referral into routine clinical workflows, healthcare systems face significant challenges in implementing HRSN screening and referral processes at scale.

Objectives:

This study explores the early implementation of HRSN screening and referral across a multistate healthcare system, using the Health Equity Implementation Framework (HEIF) and Knowledge-to-Action (KTA) Framework to examine multilevel barriers and facilitators.

Design:

Qualitative descriptive design.

Methods:

Semi-structured interviews (n = 23) were conducted with healthcare leaders, navigators, clinicians, and community health workers (CHW), eliciting their experience with leading and implementation of HRSN screening.

Results:

Findings reveal that many frontline staff (including clinicians, navigators, and CHWs) reported disjointed workflows, unclear referral roles, and limited communication related to HRSN implementation. They also reported distress when screening occurred without available resources to address identified needs. CHW’s explained their pivotal but under-integrated roles, serving as relational and cultural bridges between health systems and communities. All participant cohorts identified organizational and interpersonal misalignments between implementation mandates and on-the-ground realities. Suggested strategies for improvement included role-specific training, participatory design, improved integration of CHWs into care teams, feedback loops, and locally adapted referral protocols.

Conclusion:

These findings reinforce the value of frontline staff knowledge and experience to ensure robust implementation of HRSNs. Aligning system-level priorities with the complex realities of care delivery is essential for realizing the promise of HRSN screening as a tool for health equity.

Introduction

Health related social needs (HRSN), including food insecurity, housing instability, transportation barriers, and financial strain, are closely linked to adverse health outcomes, especially for patients with chronic conditions.^1-4 Unlike social determinants of health (SDOH) which refer to upstream societal and structural conditions that influence population health, such as systemic racism, educational access, and economic policy, HRSNs are the more proximal, individual-level manifestations of these social determinants that affect patients’ ability to engage with and benefit from healthcare. ⁵ HRSNs contribute to disparities in morbidity and mortality and addressing them is increasingly viewed as a core component of high quality, patient-centered healthcare.^1,6,7 National efforts over the past decade have pushed for the integration of HRSN screening and referral processes into routine healthcare delivery. ⁴ The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission have issued mandates, incentives, and quality measures to require healthcare systems to identify and respond to patients’ HRSNs.^8,9

Even with mandates and incentives for HRSN screening and referral, scaling HRSN remains challenging, particularly in large, complex healthcare systems.^10-12 To support HSRN screening and referral processes, a growing body of research has documented operational and ethical complexities.^13,14 Barriers, including workflow misalignment, limited infrastructure for closed-loop referrals, ambiguity around staff roles, and the emotional burden experienced by clinicians and care team members with identifying social needs without having adequate resources to address them limit successful implementation.^12,13,15,16 Patients themselves may experience frustration or mistrust when screening is conducted without apparent follow-up. ¹⁷ Technology systems are often fragmented; community resource availability is variable; and standard screening tools may fail to capture the layered and context-specific nature of patient lives. ¹⁸

Despite important contributions, much of the existing literature has focused on individual clinical sites or specific staff roles, such as physicians or social workers, offering a limited insight into how HRSN implementation unfolds across health systems with diverse settings, stakeholders, and resource landscapes.^10,16,18,19 Little is known about how centralized strategies are experienced by frontline implementers working in varied contexts, or how staff adapt in real time to institutional and community constraints. This was the first study that we know of designed to explore how healthcare leaders, clinicians, navigators, and community health workers (CHWs) experience the early implementation of HRSN screening and referral processes across a multistate healthcare system. To address these evidence gaps, we studied an enterprise HRSN rollout to understand how centralized standards are enacted, adapted, and experienced across settings. Our a priori objectives were to: (1) identify multilevel barriers and facilitators to implementation; (2) explicate how enterprise HRSN policies, tools, and training were translated to routine practice across diverse settings; and (3) characterize the strategies teams used to achieve screening and referral goals under real-world constraints. We operationalized the following research questions: (1) What inner-setting (eg, staffing models, workflows) and outer-setting (eg, CMS requirements, community resource capacity) factors impeded or enabled HRSN screening, referral, or follow-up? (2) How were enterprise standards (instrument selection, documentation, training) adapted at the clinic, service-line, and regional levels? and (3) How did teams perceive feasibility, acceptability, and appropriateness of the HRSN workflows, and where did equity gaps persist? By capturing the perspectives of diverse healthcare system actors, this study aims to generate practice-based insights that inform more equitable, sustained implementation of HRSN interventions in real-world healthcare settings.

Methods

This study employed a qualitative descriptive design with a phenomenological orientation to explore how healthcare leaders, clinicians, navigators, and CHWs experienced the implementation of HRSN screening and referral processes across a large, multistate healthcare system. Qualitative description was selected for its suitability in applied health research, allowing for comprehensive, low-inference summary of participants’ experiences in their own language. This approach was particularly appropriate for capturing the practice-based realities and implementation challenges within complex healthcare settings. While the study examined system-wide implementation processes, it also intentionally elicited and integrated the perspectives of CHWs, recognizing their unique roles as trusted connectors between clinical systems and the communities most affected by social risk.

Conceptual Frameworks

This study was guided by the Health Equity Implementation Framework (HEIF), and the Knowledge to Action (KTA) Framework, with a phenomenological orientation informing interview guide development and interpretive strategy.^20,21 Together these frameworks offered complementary insights into the factors influencing HRSN implementation and the processes by which knowledge about HRSN screening was translated into practice.^20,21

HEIF served as the primary analytic framework, supporting a multilevel exploration of equity-related factors such as trust-building, cultural responsiveness, institutional constraints, and system fragmentation. It extends the Consolidated Framework for Implementation Research (CFIR) and includes domains such as Innovation Characteristics, Recipients, Inner Context, Outer Context, and Implementation Process.^21,22

KTA complemented HEIF by offering a pragmatic roadmap to examine how healthcare system leaders’ plan for HRSN implementation was disseminated, adapted, and enacted. ²⁰ The KTA cycle conceptualizes the implementation process, encompassing identifying problems, adapting knowledge to local context, assessing barriers, implementing interventions, and sustaining change. It informed interview guide and allowed us to probe issues such as training, feedback loops, and sustainability planning. ²⁰

This integrated approach enabled us to explore both what factors shaped the HRSN implementation (HEIF) and how the HRSN interventions were operationalized (KTA).^20,21 For example, while HEIF helps identify institutional mistrust and role ambiguity as key barriers (Recipient and Inner Context domains), the KTA framework helped us examine how, or whether, factors such as institutional mistrust and role ambiguity were addressed through knowledge translation activities such as staff education or screening protocol adaptation.^20,21

A phenomenological orientation further enriched this approach by centering participants’ lived experiences and ethical reflections, particularly by frontline workers. ²³ This lens helps illuminate the emotional and relational labor in implementing HRSN initiatives, bridging the structural insights from HEIF and the procedural logic of KTA.^20,21

Setting

During the study period, Advocate Health, a large, multistate healthcare system spanning the Midwest and Southeast, rolled out a plan for HRSN screening and referral. ²⁴ Following the 2022 strategic combination, a centralized governance council representing quality, emergency care, inpatient care, primary care, community health, information technology, analytics, established system standards and initial Key Performance Indicators, with regional task forces adapting plans to service-line workflows to comply with accreditation and CMS mandates.^25,26 The single electronic health record (EHR) supported a common HRSN instrument, standardized data fields, and an embedded referral database, enabling consistent documentation of screening across campuses serving urban, suburban, and rural populations. Building on the Accountable Health Communities Health Related Social Needs Screening Tool, the condensed EHR module was designed to systematically identify patients’ unmet social needs within routine clinical workflows. ²⁴ This tool integrates a brief, validated questionnaire into the EHR, focusing on five core domains: housing instability, food insecurity, transportation barriers, utility assistance needs, and interpersonal safety. ²⁴

Participants

We conducted semi-structured interviews with healthcare leaders, clinicians, navigators, CHWs who worked within Advocate Health. ²⁵ Eligible participants were included in the study if they were employees of the health system who engaged in HRSN implementation either from a leadership or implementer perspective and were English speaking. They were excluded from the study if they were not employed by the health system or did not engage in HRSN implementation within their current role. Our qualitative sample overrepresented the Southeast region implementers and clinicians, where adoption progressed earliest.

Recruitment

Participants were recruited using a combination of convenience and snowball sampling strategies. We used role-based sampling to capture heterogeneity across key implementation actors (system leaders, clinicians, navigators, CHWs) and care settings (primary care, oncology, urban/suburban/rural). This aligns with qualitative description and phenomenological orientation, prioritizing information-rich cases able to speak to multilevel barriers and practice adaptations. Leaders were sampled to illuminate innovation origin, inner/outer context, and process design; clinicians/navigators to capture workflow integration and recipient-context interplay, CHWs to foreground equity, trust building, and community interface. We intentionally oversampled CHWs because (a) they hold unique, equity-salient, experiential knowledge central to HEIF’s Recipient/Outer context domains, and (b) early stage HRSN implementation disproportionately relies on CHW-mediated adaptation. ²¹ This role-weighting is consistent with equity-centered implementation research that privileges the perspectives of those most proximal to the intervention’s real-world enactment. Additionally, we oversampled in the Southeast region because this was where the leadership for the HRSN rollout was centered and where most early implementation occurred.

Initial outreach emails were sent to healthcare administrators, clinical staff, and CHWs known to the research team through prior partnerships within the Advocate Health enterprise. ²⁵ To identify participants with direct experience across diverse roles and care settings, we invited these individuals to participate and asked them to refer colleagues who were familiar with or involved in the implementation of HRSN screening and referral decision making or implementation processes. All participants were provided an information sheet describing the study and gave verbal consent prior to the interview.

Data Collection

We used interview guides designed using HEIF, KTA, and phenomenology to ensure domain coverage of the research aims.^20,21 Leader/clinician items were derived from the KTA cycle (problem identification, adaptation to context, barriers assessment, implementation, evaluation, sustainability). First, participant role and context captured respondents’ positions and responsibilities in HRSN implementation. Second, the research (knowledge creation/selection) domain explored rollout goals, catalysts/mandates, environmental scans of existing screeners, stakeholder input (providers, patients), development processes and evidence base, and pilot testing procedures and outcomes. Third, the translation (adaptation/implementation) domain examined required infrastructure (staffing, digital tools, workflows), communication channels, integration with CHW roles, training content and ownership by audience, and mechanisms for incorporating implementer feedback. Fourth, the evaluation (monitoring) domain addressed success metrics and data sources for implementation, institutional, and patient impact, including responsibility and cadence for data collection. Finally, the institutionalization (sustainment/scale) domain probed ongoing training (onboarding vs incumbents), continued evaluation, and quality improvement structures and accountability ²⁰ (see Table 1). We assessed CHW perspectives using a phenomenological interview guide structured by the Health Equity Implementation Framework.^21,23 Domains included: (1) motivation and pathways into the CHW role; (2) training effectiveness and equity relevance (content, gaps, additional needs, impact on confidence/competence, routinely applied skills); (3) role enactment within care teams and systems (integration, supervision/support, facilitators/barriers to performing duties, navigation of healthcare and community resources); and (4) professional development and sustainability (career goals, advice to new CHWs). This structure foregrounded equity determinants at multiple levels (individual, inner setting, community/outer setting) and mechanisms affecting CHW-enabled access and trust ²¹ (Table 2).

Table 1.

Interview Guide for Leaders and Clinical Staff Based on the KTA Framework.

Participant information  1. Could you describe your current role?  2. What role do you play related to HRSN and implementing HRSN practices at this healthcare institution? Research phase  1. Please describe the goal of the health-related social needs screening rollout.  2. What was the impetus of the new screeners and materials? (probes: what guidelines needed to be met?)  3. Could you describe preliminary research and data collection (probes: examining what screeners were already in place, gauge the opinions of providers who will be implementing, ask patients their opinions, examine where there were gaps in current practices)  4. Could you describe how the HRSN materials were developed? (probes: who played a role in developing, origin of questions [evidence-based?])  5. What kinds of pilot testing was done with these materials?  6. Who conducted the testing?  7. What were the outcome of this testing? Translation phase  1. What infrastructure was needed for implementing the SDoH materials? What of this already existed vs what needed to be built (probes: staffing, online materials, workflow processes)  2. What channels were used to inform potential implementers (providers, admin) of the changes?  3. Please discuss any effort to integrate the SDOH rollout with Community Health Worker roles and functions.  4. What kind of training was provided to prepare the implementers (healthcare providers vs Nursing staff vs CHWs)? Who is responsible for compiling training materials? Providing training?  5. Did you receive feedback from implementers?  6. What kind of feedback did they provide?  7. How was it incorporated? Evaluation  1. How will the success of the HRSN material implementation be measured? (probes: What types of data will be collected? By whom? From whom? At what intervals?)  2. How will the success of the HRSN material impact on the institution be measured? (probes: What types of data will be collected? By whom? From whom? At what intervals?)  3. How will the success of the HRSN material impact on the patients be measured? (probes: What types of data will be collected? By whom? From whom? At what intervals?) Institutionalization phase  1. What ongoing training will be provided for healthcare teams? Who will be responsible for training? (probe: for existing providers/admin vs new hires)  2. What ongoing evaluation will be done? Who will be responsible for evaluation?  3. What quality improvement practices are in place? Who will be responsible for QI?

Table 2.

CHW Interview Guide Using a Phenomenological Approach.20

Motivation and initial training  1. What motivated you to get trained as a CHW? Training effectiveness and impact  1. Tell me about your overall experience with the CHW training. What aspects made the most significant impact on you?  2. What are the gaps in the current CHW training program?  3. What additional training do you believe would be helpful for CHWs?  4. How has your training affected your confidence and competence as a CHW?  5. What specific skills or knowledge areas from your training do you use regularly in your work? Role/experience  1. What is your current role and what is your experience with connecting patients to healthcare and community resources?  2. What are you experiences working as a CHW within healthcare teams?  3. How do you feel supported in your role?  4. What are opportunities to improve support for your role?  5. What do you feel are the biggest facilitators or barriers to you being able to perform your job duties? Personal and professional goals  1. How do you envision your career as a CHW evolving in the next few years?  2. What advice would you have for a new CHW?

Two implementation scientists and one qualitative methodologist reviewed the guides for clarity, relevance, and redundancy. We then conducted cognitive pretesting with two non-sample staff members (one leader equivalent and one CHW) to evaluate comprehension, retrieval, and response processes; feedback led to wording simplification, added probes on role responsibilities, and removal of overlapping questions. Interviewers received a shared protocol with standardized openers, neutral prompts, and probe lists; we used a structured introduction and closing checklist to maintain procedural consistency. Participants who consented to be interviewed were emailed an information sheet prior to the telephone or virtual interview and verbal consent was confirmed before the interview began. Written consent was not required due to the minimal risk of harm. The study was approved by the Wake Forest School of Medicine Internal Review Board (approval no. IRB00099101). Interviews ranged between 13 and 57 minutes (average length = 34 minutes). Two formally trained qualitative researchers (RZ, SB) with over 10 years research experience, performed the interviews after participants provided verbal consent and took interview notes after each interview. RZ and SB had only professional interactions with most participants prior to study commencement. All interview participants were compensated with a $50 gift card. ²⁷

Data Analysis

All interviews were audio-recorded, professionally transcribed verbatim, and de-identified prior to analysis. The research team employed a thematic analysis approach, combining both inductive and deductive strategies to develop a rich understanding of participant experiences. ²⁸ Two experienced, female qualitative researchers (AA, RPZ), one with over 5 years’ experience implementation science (RPZ), led the analytic process and trained two additional team members (CS, RS) in qualitative coding using Atlas.ti version 25. ²⁹ Training included iterative review of transcripts, joint coding exercises, and reflexive discussions to promote consistency and analytical rigor across coders.

The team first conducted open coding to identify salient concepts emerging from the data, using a subset of transcripts to co-develop an initial codebook. Once coding consensus was achieved, the full dataset was coded independently by at least two researchers per transcript. The team met regularly to refine codes, resolve discrepancies through discussion, and update the codebook as needed to reflect emergent themes. We assessed thematic sufficiency iteratively, considering (1) narrowness of aim (early HRSN implementation within one system), (2) sample specificity (predefined roles with CHW vs. other roles), (3) theoretical anchoring (HEIF/KTA), and (4) quality of dialogue.^20,21,30 Role-stratified checks showed no new codes after CHW10 among CHWs and after P7 among other roles. Following thematic coding, we mapped data to HEIF domains to organize and interpret findings. ²¹ This framework-guided organization enabled systematic identification of multilevel barriers, facilitators, and equity-relevant dynamics shaping implementation processes.

Validation of Findings

To enhance the trustworthiness and validate findings, we conducted member-checking with participants. For healthcare leaders and clinical staff, themes and illustrative quotes were shared via email, and participants were invited to provide written feedback on the accuracy and interpretability of the results. For CHWs, we facilitated a virtual focus group where participants reviewed preliminary themes and discussed how well these interpretations reflected their lived experiences. This session offered opportunities for clarification, elaboration, and critique, which informed subsequent refinements to thematic summaries, and added any salient topics that were missing.

To further strengthen analytic rigor, the study team worked with an independent qualitative researcher (AC) to review the original code reports, code summaries, and thematic findings and mapping.^31,32 After independently reviewing these materials, the qualitative researcher provided feedback to the team on overall thematic findings and mapping for consideration. Together these processes allowed the research team to refine themes and confirm credibility.

Results

The final composition of participants included healthcare leaders overseeing HRSN implementation across the enterprise 31% (n = 7), and frontline staff, including clinicians 17% (n = 4) who worked in primary and oncology care settings across the southeast, navigators 9% (n = 2), and community health workers 43% (n = 10) who provided HRSN screening and referrals for patients across the southeast region for a total of 23 participants. Of the participants, 87% (n = 20) were female, 48% (n = 11) White, 31% (n = 7) Black, and 21% (n = 4) Hispanic, providing contrastive perspectives to examine how centralized strategies were experienced across implementation actors, consistent with the study’s objectives ³³ (see Table 3). Two people refused to participate citing time constraints and two people refused due to their supervisor’s instruction. Participants revealed several key factors influencing the implementation of health-related social needs (HRSN) screening and referral processes. Across 23 interviews, we identified 12 themes mapped to HEIF domains ²¹ (see Table 4).

Table 3.

Demographics of Participants.

Demographics	Participants n (%)
Sex
Male	3 (13)
Female	20 (87)
Race/ethnicity
White	11 (48)
Black	7 (31)
Hispanic	4 (21)
Role
Healthcare leader	7 (31)
Navigator	2 (9)
Community health worker	10 (43)
Clinician (advanced practice provider, physician)	4 (17)
Health system location
Charlotte, NC	6 (26)
Milwaukee, WI	2 (9)
Winston Salem, NC	15 (65)

Table 4.

Themes Mapped to HEIF Domain with Representative Quotes.

HEIF domain	Theme	Representative quote
Outer setting: community and policy factors influencing implementation	External mandates catalyzed scale and entrenched a compliance mindset that outpaced capacity.	“We’re screening at such a high rate. . . the expectation is that referrals are going to increase significantly” (P1.5) “It’s a check-the-box on what the requirements are. . .but we like to think of ourselves as a leader [of HRSN implementation]” (P6)
	Screening volume expanded and outpaced community capacity, creating gaps between identification and action	“Housing is a challenge, especially in rural areas. . . you’re up against the wall to really try and find those resources” (CHW3) “. . .the actual daily medical care is only about 20 percent of the success of somebody’s health” (P9)
Implementation process	Central governance enabled enterprise rollout after a multistate strategic combination, but concentrated execution burdens created bottlenecks.	“If you’re standing up six workstreams under a subcommittee, there has to be someone [from the governance team] there that knows what’s happening in each one of those” (P1) “We’re building an impact evaluation strategy to look at pre- and post-data utilization trends” (P1) “We are trying to come together to build one approach and bring the regions together” (P1)
	Standardization improved data visibility but required structured flexibility for local fit and flow.	“I would love for us to see more tailored solutions based on where you practice, how you practice, what’s your role, what’s your profession” (P4) “Success looks like reliably screening at scale. . .in a patient-centered, culturally sensitive way” (P10)
	Education built awareness, but lacked role-specific, workflow integrated training to drive consistent action.	“Am I supposed to have seen communication through an email on that [HRSN implementation]? ‘Cause I don’t think that I have” (P5) “The video was one of the [only] tools that I think was shared with our team. . . I have not been—myself, I have not been aware of any other forms of materials or education related to that” (P4) “We need clear guidelines on how these questions are asked and the appropriate time to ask the questions” (P6) “How to screen in a culturally sensitive manner and how to address patient resistance—needs to be part of the training” (P10)
	Digital infrastructure enabled scale but lacked interoperability, flexibility, and feedback loops, which shifted work to staff.	“That agency’s not on the platform. . . There’s no way for the agency to put in a note and let us know if the loop was closed” (P2) “We have to build capacity in the community-based organizations if we keep referring. They don’t have systems to respond. . .” (P10)
Inner setting: (organizational factors)	Enterprise standardization advanced intent, but funding, staffing, and productivity policies constrained team-based follow through	I think awareness that there was change [HRNS implementation] and recognition of wanting to learn more about social drivers of health, and I guess periphery that, yes, I noticed a change in the panel of Epic and the request to gather that information,—I think that’s where it stopped (P7) “It [official caseload] says 25 cases, but it’s really more like 50 once you factor in everyone in a household” (CHW6) Your most elaborate and well-planned social driver outreach plan could fail if that end of the line is not robust and is not supported appropriately. (P6) “It’s limiting for me [policy preventing health fair involvement]. I used to go to health fairs” (CHW11)
Innovation characteristics (HRSN implementation)	Integrating HRSN screening and referrals into clinical workflows added to time pressures, constraining reliable implementation amid competing demands	“Right now, it’s [HRSN screening]is part of the check-in process which is already painful and is already” (P9) “None of the answers translate over to that form, so you gotta do it [chart] again anyways” (P3)
Characteristics of the individuals (staff, clinicians, patients)	Moral distress and workload strain undermine screening fidelity and adoption.	“If that person doesn’t know where they’re going to sleep tonight, it doesn’t really matter what medication you prescribe” (P3) “If you are asking clinical teams. . .to screen, that’s all well and good, but you darn well better have the infrastructure to manage what happens on the other end of a positive screen” (P10)
	Role ambiguity and skill gaps limit actionability.	“Assessment skills seem very simple, but apparently they are not a given for everybody. . .just knowing how to assess in a way that is not interrogating patients but you’re finding out how they’re doing and what they need” (CHW12) “I’m not sure our frontline people understand why we are collecting this data—why CMS is making us collect this data” (P9)
	CHWs are trusted connectors, but inconsistent role integration blunts their impact.	“Sometimes they can put a community health worker on a pedestal. . .and no one knows everything” (CHW5) “We need a robust team of community health workers. . . We’re going to have to put some sort of infrastructure in place” (P1) “A lot of times, the providers don’t have time. . .it’s [the referral is] vague, like ‘patient needs help’. Then I have to go and do a full assessment again myself” (CHW8) “I believe our social workers are more familiar with community health workers than the nursin’ staff. When they send us a referral it’s one that I know it’s somethin’ that we will definitely be able to help” (P3) “It was very impactful where we worked together in tandem, and it was great” (CHW5)
	Trust, cultural responsiveness, and access drive patient engagement, analogous to chronic disease management versus a one-time task Trust, cultural responsiveness, and access drive patient engagement, analogous to chronic disease management versus a one-time task.	“It’s not just one referral. . . it’s everything else that comes out once you build trust” (CHW6) “Even though I am a Black woman, I can’t speak for every Black person. Cultural humility matters” (CHW8) “A lot of people just need to talk, and they need someone to listen. A lot of people are distrustful” (P5)

HRSN Implementation

HRSN implementation proceeded in phases: Pre-merger legacy efforts (prior to 2021) consisted of heterogeneous, paper or EHR-light pilots in select ambulatory clinics, inpatient settings, or care management programs. In 2022-early 2023, the system aligned on a single instrument, built a standardized screening flowsheet, and initiated go-lives in primary care, inpatient, and ED sites. From mid-2023 through 2024, the rollout scaled to additional sites, launched an electronic referral hub embedded in the EHR, and deployed centralized dashboards to monitor screening completion. In 2024 to 2025, work focused on consolidation and optimization: refining workflows and roles, embedding CHWs at selected sites with centralized governance, and instituting periodic feedback reports. Training and enablement comprised system-wide primers, microlearning videos, presentations at grand rounds, and a dedicated HRSN webpage with resources, although this was relevant most to a legacy location. Technology enablement included the EHR-embedded HRSN flowsheet, a referral hub for on-platform partners, and closed-loop tracking at one health system location. Partnership development involved onboarding community-based organizations to the hub where feasible, developing vetted resource lists for off-platform partners, and convening periodic meetings to align referral criteria and capacity.

Outer Setting: Community and Policy Factors

Theme 1. External Mandates Catalyzed Scale and Entrenched a Compliance Mindset That Outpaced Institutional Capacity

Federal and accreditation standards, especially CMS measures, were the primary triggers for enterprise adoption and standardization, generating urgency, executive attention, and performance targets. “CMS says you must, so you must” (P9). Yet the compliance frame constrained experimentation and diverted attention from resourcing, leaving frontline teams to meet metrics without parallel investments in referral infrastructure or workflow support. Clinicians and CHWs experienced downstream pressure to screen without assured follow-through, reinforcing perceptions of “checking the box” rather than meaningful care. One leader noted, “We need a robust team of community health workers. . . We’re going to have to put some sort of infrastructure in place” (P1).

HEIF/KTA synthesis: Strong outer setting policy signals accelerated uptake of HRSN implementation, but induced process rigidity; in KTA terms, spread outpaced adaptation and resource mobilization, potentially weakening the “action” phase.^20,21

Theme 2. Screening Volume Expanded and Outpaced Community Capacity, Creating Gaps Between Identification and Action

Routine HRSN screening was widely endorsed, but rapid scale-up produced referral volumes that exceeded community capacity, especially in post-COVID and in rural areas, decoupling identification from resolution in key domains (eg, housing, transportation). Outer setting constraints included funding shortfalls and limited-service availability which reduced partner capacity for timely referrals and follow-up in some regions. One leader noted, “Our nonprofit community is not prepared for what we’re expecting of them” (P6). Inner setting gaps included uneven awareness of local partners and weak infrastructure for managing system-community partnerships which led to fragmented, ad hoc workarounds. Skepticism rose around mandated screening absent response pathways, eroding perceived value, “If we’re just screening people for the idea of screening and not having a response or a solution, how much are we helping or hurting our patients?” (P4)

HEIF/KTA synthesis: Outer-setting resource deficits constrained inner-setting processes, breaking the screening-to-action chain. Align scope and pace of implementation with partner capacity: establish formal linkages and agreements, invest in community capacity in priority domains, build shared referral infrastructure with closed-loop tracking, and phase expansion based on readiness and measurable throughput.^20,21

Implementation Process

Theme 3. Central Governance Enabled Enterprise Rollout After a Multistate Strategic Combination, but Concentrated Execution Burdens Created Bottlenecks

A centrally anchored governance model within the enterprise set strategy, benchmarks, and performance targets, while also coordinating multistate task forces across primary care, inpatient, and ED settings. One leader emphasized their desire for unified planning: “We had a target of having a unified plan around HRSN screening and referral” (P11). Central coordination allowed for aligned tools and workflows while also navigating legacy variation after the strategic combination. Equity and normalization of routine HRSN screening were stated as explicit goals, with screening rates serving as key performance indicators. However, day-to-day implementation often rested with a small cadre of leaders, raising sustainability concerns when capacity was localized to the teams they oversaw.

HEIF/KTA synthesis: Benchmarking and key performance indicators drove consistency, but concentrated execution signaled vulnerability in spread and sustainment. HEIF points to strong process design, but limited resourcing for enactment; KTA indicates that implementation and sustainment steps were under-supported relative to planning.^20,21

Theme 4. Standardization Improved Data Visibility but Required Structured Flexibility for Local Fit and Flow

Systematization moved HRSN screening into the EHR, which improved data visibility and comparability. Prior to HRSN implementation, one leader noted that, “Not all [HRSN] screening even made it into the EMR. We didn’t know consistently whether we were even intervening with patients in a macro way around social drivers of health” (P11). Centralized protocols improved data capture but was seen as rigid and disruptive to clinic flow, which dampened staff engagement, and outpaced referral capacity in some settings. Frontline staff emphasized the need for readiness assessments, role-clarified workflows, and tailored instruments to avoid burden and maintain patient-centeredness. Staff valued scalable consistency but expressed need for adaptations (eg, timing, role-specific scripts, workflows) and infrastructure to act on identified needs; without this balance, standardization reproduced inefficiencies rather than enabling whole-person care.

HEIF/KTA synthesis: HEIF emphasizes fit to inner-setting conditions; KTA highlights planned adaptation and iterative tailoring during “adapt to local context” and “implement/monitor” steps.^20,21

Theme 5. Education Built Awareness, but Lacked Role-Specific, Workflow Integrated Training to Drive Consistent Action

The organization offered primers, video modules, presentations at grand rounds, and a dedicated HRSN webpage, creating a shared baseline. “We developed a primer on what social drivers of health care, but this was more of a general foundation” (P10). HRSN rollout communication was uneven (“It felt like a game of telephone” (P4)) and educational content was insufficient for application to daily practice. One staff person noted that training would be more beneficial “when it’s less cerebral and more tell me what we need to do” (P7).

Staff prioritized practical, role-specific training integrated with workflow:

• Clear “why” behind screening to build buy-in among teams and patients.

• Concrete, stepwise guidance on culturally responsive, patient-centered screening (what to ask, when to ask, and how to respond).

• Training on community resources, referral pathways, and handoff protocols.

• Embedded, just-in-time supports (quick guides, infographics, EHR tips) and annual refreshers

• Dedicated and up-to-date webpage with blogs and emerging educational topics

Role-specific content, particularly for CHWs, on motivational interviewing, trauma-informed care, safety, and local resource navigation. “[Motivational interviewing] really helped me, explained to me a little bit more into social determinants of health, and how to approach certain conversations, how to empower the community versus handing them solutions” (CHW1). “We need clear guidelines on how these questions are asked and the appropriate time to ask the questions” (P6).

HEIF/KTA synthesis: Knowledge and skills were unevenly distributed and misaligned with roles; in KTA, knowledge creation and dissemination occurred without sufficient training and integration into point-of-care action supports.^20,21

Theme 6. Digital Infrastructure Enabled Scale but Lacked Interoperability, Flexibility, and Feedback Loops, Which Shifted Work to Staff

Technology was necessary to operationalize and implement HRSN implementation. However, many participants identified gaps in interoperability, data tracking, connectivity with community partners, and limited feedback loops produced discontinuity and workarounds rather than reliable use.

Subtheme 6.1. Interoperability Gaps Undermined Closed-Loop Coordination

The EHR often failed to communicate with one another or with external community-based organizations, especially those not integrated into the platform. These gaps led to:

• Limited visibility into screening/referral status across clinics and regions.

• CBO connectivity gaps (off-platform partners, paper/phone workflows, limited IT capacity) which impeded bidirectional communication and confirmation.

• Lacking feedback and real-time status updates, which prevented tracking of completion and outcomes.

Some participants described workarounds, “We’ve created our own resource list to be more effective than utilizing the hub [electronic referral platform] ‘cause the hub does not have it listed [pantry partner location]” (P2).

Subtheme 6.2. Value Depended on Operational Flexibility and Role-Aligned Design

Participants viewed technology as necessary for consistency and scale, but cautioned that rigid, over-engineered systems prompted avoidance and workarounds. Leaders advocated a dual approach: enterprise infrastructure (shared tools, core workflows, common data elements) paired with service line adaptations (role-specific screens, timing, and handoffs) to fit local contexts. Key shortcomings included immature closed-loop referral functionality, limited longitudinal tracking, and insufficient surfacing or just-in-time guidance within clinical workflows.

“We can develop the infrastructure, the technology, and some macro workflows, but then must consider adaptations needed for each service line. . . We’re going to take the best practices from both regions, look at those together, look at how technology can enable the screening in a more efficient manner” (P10).

HEIF/KTA synthesis: Technology functioned as an implementation determinant. Without interoperable data standards, bidirectional CBO links, embedded guidance, and routine feedback, knowledge did not translate into action. Effective implementation requires tools that allow local fit while standardizing core data, enable real-time CBO communication (including capacity signals), embeds role-specific workflows, and generate dashboards for iterative learning and equity monitoring.^20,21

Inner Setting (Organizational Factors)

Theme 7. Enterprise Standardization Advanced Intent, but Funding, Staffing, and Productivity Policies Constrained Team-Based Follow-Through

System level standardization clarified HRSN implementation goals but under-resources the relational, longitudinal work required for the resolution of social needs. Participants described uneven referral integration, variable staffing models, and productivity timelines misaligned with longitudinal social care, which produced inconsistent execution of action for identified social needs. A team-based approach was widely endorsed, but costly and logistical difficult to sustain at scale: “Doing that at scale is costly” (P10). Another leader acknowledged the chronic nature of addressing social needs, reflecting the difficulty of achieving rapid resolution, “A lot of the things [social needs] that we’re trying to help remedy are chronic issues” (P4). Several CHWs described productivity targets and fixed timelines (eg, 90-day goals) that conflicted with chronic, non-linear social needs intervention. Policies also limited proactive engagement (eg, limits on CHW outreach at health fairs).

HEIF/KTA synthesis: Inner setting structures standardized intent but underfunded action. Re-aligned financing, staffing distribution, and productivity policies could help support closed-loop, longitudinal coordination. Reorientation toward equity requires dedicated funding for multidisciplinary teams with protected coordination time, standardized referral infrastructure with role clarity, enabling policies for CHW outreach, and performance metrics that value resolution and sustained engagement with feedback loops.^20,21

Innovation Characteristics (HRSN Screening and Referrals)

Theme 8. Integrating HRSN Screening and Referrals into Clinical Workflows Added to Time Pressures, Constraining Reliable Implementation Amid Competing Demands

Added HRSN tasks increased friction in already burdened workflows, reducing fidelity and consistency. Leaders reported collaboration with information technology (IT) to design flexible workflows, acknowledging that staff already experience “death by clicks in Epic” (P1). Despite these intentions, clinicians, social workers, and CHWs expressed concerns about the added burden and disruptions of assessing and addressing HRSN in the clinical setting, emphasizing the need for seamless, low-friction processes: “a process that doesn’t involve a ton of time and maybe not a ton of effort. . . among seeing the other 25 patients that day” (P3). The mechanism was two-fold: screening tasks were appended rather than embedded, and accountability for follow-through was inconsistent, leading to variable uptake and execution across sites. Additionally, competing demands reduced use despite IT collaboration to design flexible workflows.

Subtheme 8.1. EMR Screening and Referral Tool Usability Had Weak Points

Several frontline staff cited excessive navigation, duplication, and incomplete/inaccurate resource listings. As one clinician put it, “If I’m having to click, click, click a million times to get from a table to link. . .my eyes probably don’t even go over there [HRSN screening flowsheet]” (P5). Off-platform referrals often lacked transparency, impeding closed-loop tracking: “That agency [to which the referral was placed is] not on the platform. . . There’s no way for the agency to put in a note and let us know if the loop was closed” (P2).

HEIF/KTA synthesis: Poor workflow fit and weak implementation supports degraded fidelity; KTA indicates incomplete “implement/monitor” steps. Tools must embed low-friction tasks, assign clear accountability, and enable closed-loop tracking to convert screening to action.^20,21

Characteristics of Individuals

Theme 9. Moral Distress and Workload Strain Undermine Screening Fidelity and Adoption

Identifying needs without reliable response pathways produced moral distress, reduced perceived value of screening, and contributed to burnout. Across roles, participants expressed ethical tension when identifying social needs they could not reliably address. Leaders recalled trainees spending extended visits with patients facing acute social risks without solutions: “She can’t feed her children” (P1). Frontline staff named the disservice of asking without acting. Many questioned the value and potential harm of screening when follow-up support was uncertain, “We felt like it was a disservice to our patients to ask certain questions if we didn’t have a solution” (P2). Leaders linked this to disengagement: teams “don’t want to experience the moral distress of screening and not having those needs met” (P10). High caseloads and fragmented systems compounded distress, contributing to compassion fatigue and burnout.

HEIF/KTA synthesis: Individual beliefs and workflow pressures hindered adoption. KTA suggests to pace spread of an intervention with response capacity; build supports prior to scaling to prevent harm: dependable resource pathways, closed-loop coordination, reflective supervision, and surge capacity to prevent harm.^20,21

Theme 10. Role Ambiguity and Skill Gaps Limit Actionability

Unclear post-screening responsibilities, combined with incomplete referrals and limited role-specific training slowed response and reduced confidence in HRSN screening and referrals. This reduced confidence in screening down by staff and often forced repeated assessments. A social worker observed, “not all providers are equipped to ask those questions. . .historically, you go to the doctor for a medical reason” (P2). Staff sought concrete guidance on how to perform handoffs for positive screens and available pathways to address social needs: “what can we do with that information [identified HRSN]? How can we refer them to Meals on Wheels, or how can we get them in touch with a community health worker to bring them a food box?” (P3)

HEIF/KTA synthesis: Role clarity and competence are core determinants. KTA points to defining handoffs and accountable owners, developing role-specific training and decision support, and establishing minimum referral data standards in the EHR to accelerate action.^20,21

Theme 11. CHWs Are Trusted Connectors, but Inconsistent Role Integration Blunts Their Impact

CHW’s cultural alignment and community-rooted trust improved patient engagement, but unclear scope and weak integration with clinical teams limited coordination and efficiency. Participants across all roles described CHWs as essential, trusted connectors whose cultural alignment and community-rootedness increased patient engagement: “CHWs were able to develop a lot of trust with patients who may have been skeptical of the health system previously. . . patients were more open to recommendations” (P7). Yet unclear scope and inconsistent integration into health care teams impeded coordination, and incomplete or siloed referrals forced CHWs to restart assessments: “They [referring clinic team] talk to the patient. . .but they don’t talk to us;” (CHW5) “Even though the referral navigator. . .gets an overview what they might need. . .I’ll start over from the beginning” (CHW3). Some relied on personal networks to fill system gaps, but this created variability and equity risks: “Mine is word-of-mouth type thing, because I’m known in the community. . .I very seldom get referrals now from the [health] system” (CHW11). Structured collaboration with social workers and nurse navigators streamlined workflows and reduced duplication: “I was able to pull off information from them, and they were able to pull information off me. . . It was less stress and less work and less hands in the pot making a messy soup” (CHW5). A clinician emphasized the value of clearer inclusion: “I think CHWs could be great partners. . .not only in collecting the information but also helping direct patients to resources” (P7).

HEIF/KTA synthesis: Team functioning and communication infrastructure are pivotal. KTA supports formalized scopes, co-location or assigned designated points of contact with clinical teams, shared documentation, and closed-loop communication to realize CHW’s value.^20,21

Theme 12. Trust, Cultural Responsiveness, and Access Drive Patient Engagement, Analogous to Chronic Disease Management Versus a One-Time Task

HRSNs are layered and dynamic, and engagement requires sustained, trust-based relationships, cultural/linguistic alignment, and accessible (including non-digital) pathways. Leaders stressed human connectivity and patient-centered approaches: “If they haven’t emphasized the role of the human connectivity in an individual assistance person, it could be a community health worker. . . there’s gonna be an awful lot of people who have the greatest needs and can be most help by the system that are not gonna know how to navigate to get the help they need” (P6). CHWs described long-term, trust-based engagement for people who face multiple intersecting barriers that lasted several months, requiring substantial emotional labor: “A referral might look like one thing, but then you end up taking several months to unpack it” (CHW6). Trust, privacy concerns, language, and digital access shaped disclosure and follow-through: “We’re asking them to ask some very personal questions, and we know historically, there’s a lot of groups that have low levels of trust in healthcare” (P2). Participants that to meet patients “where they are” requires tailored, non-digital options and cultural humility: “We have some patients who are not digital. . . we need to be very creative in terms of meeting the patient where they are” (P10).

HEIF/KTA synthesis: Patient needs/preferences and equity context are central determinants. KTA calls for tailored approaches, community engagement, linguistically/culturally aligned options, non-digital pathways, and use of iterative monitoring to sustain engagement over time.^20,21

Discussion

Our multi-site study indicates that successful implementation of enterprise-wide HRSN interventions hinges less on mandates or tools and more on alignment among policy, financing, organizational processes, and community partnerships. Applying HEIF and KTA, we identify where knowledge creation (standardized instruments, primers, policies) fails to convert into action (closed-loop referrals, need resolution) and specify design and governance conditions required to bridge that gap.^20,21

Key Contributions

Our analysis advances the literature in several ways. First, we delineate the compliance-to-capacity mechanism: external mandates accelerate screening but, when framed primarily as compliance, divert attention and investment from referral capacity, workflow supports, and CHW-enabled follow through. This produces a tangible “screen-act” decoupling and moral distress among frontline teams. Second, we identify an equity-relevant pathway in which outer-context resource scarcity (eg, limited CBO capacity in rural areas) interacts with inner-setting productivity policies (for example, fixed 90-day targets) to systematically impede closed-loop referrals. Third, moving beyond calls for “more training”, our data KTA ²¹ failure points, (eg, uneven dissemination, role-agnostic content, and weak workflow integration) and identify enabling features that translate knowledge into action: role-differentiated curricula, embedded just-in-time EHR supports, and routine feedback on referral outcomes.

Digital Determinants

Interoperability gaps slow data exchange and generate shadow systems (eg, parallel resource lists, manual phone follow-up, and ad-hoc tracking) that undermine reliability. Technical requirements tied to practice include standardized closed-loop referral fields, bidirectional signals of CBO capacity, and real-time status updates. Post-merger enterprise governance reduced variation in intent, yet financing models, staffing distribution, and throughput-oriented metrics remained binding constraints on team-based social care delivery. CHW implications. CHWs are pivotal to HRSN fidelity. Their work spans receiving clinical referrals, coordinating with CBOs, conduct home visits, attending health fairs, and at times transporting food and medications, placing them at the intersection of clinical systems and social care. Despite this centrality, CHWs frequently reported role ambiguity, safety concerns, limited decision-making voice, and misaligned timelines. Necessary conditions include inclusion in governance, explicit role-clarity, protected time for coordination/outreach, and safety protocols. As one participant stated, “I think that being more at the table (for decision making). . .not just asking us for our story” (CHW5). This aligns with and extends within existing research, emphasizing the importance of clearly defined roles, adequate training, and meaningful organizational integration to leverage CHWs’ full potential.^33,34

Phenomenological Insights

The participants’ lived experiences revealed a fragmented rollout marked by unclear communication and inconsistent supports. Staff described emotional and logistical burdens, including moral distress when screening proceeded without reliable follow-up resources. These accounts foreground the ethical and emotional complexities of extending care beyond clinic walls and emphasize the need for visible, trustworthy referral pathways.

Gaps Between Ideal Implementation and Practice

The KTA ideal process: (1) identify, (2) adapt knowledge to the local context, (3) assess barriers, (4) tailor interventions, (5) monitor use, and (6) sustain change was inconsistently realized. ²¹ Participants recognized the importance of addressing HRSNs, yet limited local adaptation to clinical and community contexts, insufficient role-specific training, weakened feedback mechanisms, and lack of sustained evaluative monitoring mechanisms hindered translation into practice. Informal, experiential learning and inconsistent protocol adoption led to confusion and reduced buy-in; exclusion of frontline staff from decision-making further hindered local tailoring and eroded confidence in the value of screening.

Positioning Within the Literature

These findings are consistent with prior reports of role ambiguity, provider distress, and resource shortfalls, and extend the literature by: (1) locating where KTA translation stalls; (2) linking HEIF levels to concrete operational fixes (eg, service line-specific adaptations within enterprise standards; standardized referral data elements; feedback loops); and (3) specifying CHW-centered policy levers that enable longitudinal, person-centered follow through.^{10,13,15,35,36} Prior work identifies multimodal training (eg, short videos, role-play, facilitated discussions), clear referral workflows, continuous feedback loops, participatory design, non-EHR screening options, peer champions, and site-level leadership as effective strategies, aligning closely with barriers and solutions that surfaced in our data.^{13,16,19,37,38} CHW integration is strengthened by teamwork, morale, involvement in supervision, clear roles, and adequate preparation.^19,39 Taken together, these studies underscore that effective implementation of the CHW role within the context of HRSN implementation enhances relevance and acceptability but also promotes trust and sustainability.

Actionable implications for practice include: (1) Governance and finance: Pair screening expectations with financed referral capacity (CHW FTEs, navigation time) and metrics that weight resolution and equity-stratified outcomes, not throughput alone; (2) Workforce and training: Deliver role-differentiated curricula; embed just-in-time EHR supports; provide protected coordination time; implement CHW safety protocols; include frontline staff in decision-making; (3) Technology: Standardize closed-loop referral data elements; enable bidirectional CBO capacity signaling; surface real-time referral status; reduce reliance on shadow systems; (4) Partnerships: Formalize CBO agreements with capacity signaling and clear referral criteria; convene routine joint reviews; support off-platform partners with streamlined feedback channels.

Strengths and Limitations

This study offers several important strengths. It is one of the few qualitative analyses to examine the early implementation of HRSN screening and referral across a large, multistate healthcare system using the HEIF as a guiding structure. The integration of CHW perspectives alongside those of clinicians, referral navigators, and health system leaders allowed for a multilevel understanding of both structural and relational factors shaping implementation. This study’s use of hybrid inductive-deductive approach, combined with rigorous analytic methods, including double coding, reflexive team discussion, and member-checking, enhanced credibility and interpretive trustworthiness. The inclusion of a phenomenological orientation ensured that emotional, ethical, and experiential dimensions of implementation were foregrounded, particularly among frontline staff.

Nonetheless, several limitations should be acknowledged. First, although the sample included diverse roles, it is limited to one healthcare system and included a small number of staff types, potentially reducing transferability to other roles, institutional, or geographic contexts. The role distribution is intentionally non-proportional, privileging CHW perspectives central to equity-relevant implementation dynamics; physician subspecialties beyond oncology were fewer, and the southeast was overrepresented in the sample, which limits clinical and regional comparability. Second, while participants represented multiple roles and regions, variation in implementation strategy or community resource infrastructure may not have been fully captured. Third, most of the interviews were conducted virtually, which may have constrained rapport. Finally, although CHW perspectives were deeply represented, the study was not designed to include patients or community-based staff, limiting insights into how implementation is experienced on the receiving end of the referral processes. Future research should expand to include these perspectives and examine the sustainability and impacts of HRSN implementation over time.

Conclusion

This study highlights the disconnect between health system mandates for HRSN screening and the lived realities of those tasked with implementation. While screening is increasingly framed as essential for equity and quality, our findings revealed that frontline staff, particularly CHWs, encounter disjointed workflows, limited resources, and unclear roles that constrain effective, ethical implementation. Moral distress surfaced when screening added to clinical burden or without meaningful community resource follow-up. CHWs often described relying on informal networks to compensate for systemic gaps in screening and referrals.

Implications for practice include the need for clearer communication channels, team-based workflows, and sustained investment in CHW integration and training. Policy efforts must go beyond mandates to ensure that infrastructure, community partnerships, and local adaptation are adequately resourced. For implementation science, this study reinforces the importance of frameworks like KTA and HEIF in uncovering equity-relevant barriers and points to the value of incorporating frontline experiential knowledge in strategy co-design and evaluation.^20,21 Aligning system priorities with real-world complexity is essential for delivering on the promise of HRSN screening as a pathway to more equitable, person-centered care.