Screening for Social Needs in Health Care Systems: A Quality Improvement Framework and Two Case Studies

Abstract

Public health professionals have long understood the link between social determinants of health, health-related social needs (HRSN), and health outcomes. Recently, the integration of social care to address HRSN within the health care environment has increased, spurred by payers and health systems recognizing that they will be unable to improve health equity without addressing the underlying nonclinical causes of illness. However, the integration of social care and health care is complex, involving many stakeholders within health care and social care systems, as well as the community. From September 2021 to September 2022, the Institute for Healthcare Improvement, with funding from Pfizer, supported a Learning and Action Network (LAN) involving three integrated delivery networks (IDNs) from across the United States. During the LAN, the IDNs tested social care integration strategies within their patient populations and shared results both with one another and stakeholders in their own systems to enhance the rate of learning and improvement. Detailed here are practical examples from the LAN and learnings from the participating IDNs, with a focus on HRSN screening. This paper presents the quality improvement framework for the LAN, including the use of a three-part data review process and Plan-Do-Study-Act cycles, and documents the successes and challenges faced by each of the IDNs, which include dramatic improvements in HRSN screening rates. Success in this work can be realized with intentional engagement with health care system leadership and the community, closely monitoring implementation, and by evaluating what really matters at the core of this work—achieving health equity.