Workforce Models to Screen for and Address Patients’ Unmet Social Needs in the Clinic Setting: A Scoping Review

Abstract

Objectives

While healthcare organizations increasingly aim to address the social determinants of health (SDOH) in the clinic setting, there is little guidance on which staff are best equipped to assume this role. The present study is a scoping review of the peer-reviewed literature to characterize workforce models used to screen for and respond to patients’ unmet social needs in ambulatory settings.

Methods

Four online databases were used to identify papers published until February 2021. Eligible articles were original research studies or systematic reviews that described the implementation of a standardized assessment for multiple SDOH domains and resulting activities to respond to individual patient needs (eg, referral to community resources) in ambulatory care settings.

Results

Of the 1569 articles identified, 65 met study eligibility criteria. Majority of studies had observational study designs (11% were randomized control trials). For screening-related activities, more articles reported using traditional healthcare staff (51%), such as medical providers, medical assistants, and front-desk staff, than social care staff (32%), such as social workers and student volunteers. In contrast, for response-related activities, more articles reported using social care staff (88%) than traditional healthcare staff (60%). While we found wide variations in specific team configurations and training for the roles, social care staff generally provided more intensive forms of assistance than traditional healthcare staff.

Conclusion

While this review demonstrates the breadth of models for building or deploying a workforce to integrate health and social care, it also identifies the need for rigorous research on workforce development, implementation, and effectiveness.

Keywords

scoping review social determinants of health workforce screening ambulatory care

Introduction

A growing evidence base has illustrated the impact of the social determinants of health (SDOH) on health outcomes.^1,2 According to the World Health Organization, SDOH encompass a broad set of economic, social, and political forces that shape the conditions in which all people live.³ The United States Healthy People 2030 initiative organizes SDOH into 5 broad categories: economic stability, education, social and community context, health and health care, and neighborhood and built environment.⁴ Downstream consequences of adverse SDOH at the patient-level include social needs associated with negative health outcomes, such as food insecurity, housing instability, and lack of transportation.^5,6 A multi-sector group of stakeholders including healthcare professional organizations, state governments, and federal agencies have called for action to screen patients for their unmet social needs and provide assistance within healthcare settings.^7-13 Screening activities often rely on standardized screening tools that can be self-administered on paper or tablet, or orally by clinic staff.^14,15 Assistance activities can include connecting patients with on-site clinic services (eg, food boxes), community-based organizations (eg, food pantries), and government benefits (eg, food stamps).¹⁶

While there has been emerging evidence on the implementation and effectiveness of interventions to identify and address patients’ unmet social needs in the healthcare setting,^17,18 a recent National Academies of Sciences, Engineering, and Medicine (NASEM) report revealed there is little evidence on the types of workers that are used most frequently and in which settings, the specific roles of individual staff in interprofessional teams, and the training components for each workforce model.¹⁹ The purpose of this scoping review of the peer-reviewed literature was to characterize the workforce models in ambulatory care settings to screen and respond to patients’ unmet social needs. Specifically, we aim to describe the types of staff and combinations of staff employed in diverse settings, relevant activities conducted, and staff training provided to support workers in their role. This review seeks to be a resource for practitioners and administrators working to introduce or refine social needs interventions in their clinics and to help researchers identify areas for future workforce research.

Methods

We followed scoping review methodology and the PRISMA-ScR reporting guidelines which include identifying a research question; identifying relevant studies; study selection; charting the data; and collating, summarizing, and reporting the results.^20,21 While not formally registered, the review protocol can be requested from the corresponding author.

Information Sources and Search Strategy

To identify relevant articles, we searched the databases PubMed, Web of Science, CINAHL, and the Social Interventions Research and Evaluation Network (SIREN) Evidence and Resource Library for peer-reviewed literature published until February 2021. The search strategy was drafted collaboratively by the authors and received guidance from university librarians. Articles from the search of each database were first imported into Endnote²² and then imported into Covidence,²³ to remove duplicates across databases.

Our search strategy consisted of terms from 3 main categories: the topical domain (the social determinants of health and unmet social needs), the intervention (screening for and responding to unmet social needs), and the setting (ambulatory care) (Supplemental Table S1). We then hand-searched reference lists of relevant articles to identify additional papers.

Eligibility Criteria

Included in the review were (1) peer-reviewed original empirical research or systematic reviews, (2) published in English, that (3) described the implementation of a standardized assessment of social needs (eg, using a structured screening tool) and response for multiple unmet social needs (eg, providing assistance to connect to relevant social care resources), and (4) were conducted in ambulatory, clinic-based care settings. Our review focuses on studies that screened for 2 or more domains in alignment with broader policy efforts at the state and national levels.^13,24

Articles were excluded if (1) service delivery took place in inpatient, emergency, non-clinical community-based, or home-based settings; (2) the intervention only included screening for a single domain (eg, housing); or (3) classified as opinion, editorials, guidelines, descriptive studies on the prevalence of social needs without intervention to address them, descriptions of care practice without any quantitative or qualitative data, or study protocols.

Selection of Sources of Evidence

Two team members (SS, JPB) independently conducted a title and abstract screen according to our inclusion and exclusion criteria. We resolved discrepancies in article eligibility until consensus was reached. One team member (SS) then assessed all eligible articles for study inclusion at the full-text level. A second team member (JPB) evaluated any article for which eligibility was not clear and consensus was reached between reviewers.

Data Charting Process and Data Items

A data-charting Excel template was developed by 2 reviewers to determine which variables to extract. One team member (SS) extracted data from all articles that met inclusion criteria. Data were obtained on study characteristics (study design, institutional and geographic setting, patient population), and workforce components. Workforce model components were loosely informed by the World Health Organization’s Human Resources for Health (HRH) Action Framework and the previously mentioned NASEM report.^19,25 We chose to abstract the type(s) of worker used for screening and response to unmet social needs, activities conducted by workers, and training. Another team member (JX) conducted data extraction for a random sample of 20% of the included articles for data validation, revealing a 79% agreement. Each discrepancy was reviewed and resolved by consensus, and the data extraction tables were revised accordingly.

Synthesis of Results

With input and review from the full team, 1 team member (SS) first organized articles by study design and summarized by geographic setting, institutional setting, and patient population targeted. Articles were then grouped by modes of social needs screening, response activities, and training activities, and reported by type of worker used.

Type of worker was further synthesized in alignment with the NASEM report, which categorizes the types of workers that can be used for identifying and responding to social needs as (a) the traditional healthcare workforce, and (b) the social care workforce.²⁰ The traditional healthcare workforce consists of clinical staff (eg, doctors, advanced practice providers, nurses, medical assistants) and front-desk/administrative staff. The social care workforce consists of a broader mix of workers with various levels of training, and includes both paid roles (eg, social workers, case managers, patient navigators, patient advocates, community resource specialists, community health workers, etc.) and volunteers.

Results

Selection of Sources of Evidence

After duplicates were removed from 1725 articles identified, there were a total of 1569 unique citations. Based on screening the title and abstract, 1364 were excluded and 205 full text articles were retrieved and assessed for eligibility. Of these, 65 studies were considered eligible for this review (Figure 1).

Figure 1.

PRISMA flow diagram.

Characteristics of Sources of Evidence

Of the 65 papers included in the review,^26-90 only 7 reported using randomized control trial designs^26-32 (Table 1). The remainder reported using observational study designs (eg, pre-post studies, feasibility studies, pilot studies).^33-90 Fifty-eight studies were conducted with primary care patients,^{29-31,33-70,72-74,76,78-89} 4 took place in a specialty clinics,^32,71,75,77 1 took place in urgent care,27 and 3 took place across multiple settings (eg, primary, specialty, and urgent care).^26,28,90 Majority of studies reported including academic sites (n = 40),^{29,34-39,41-44,47-59,62,63,65,66,71,72,75,77-80,82,84,85,89,90} including urban sites (n = 48),^{26-30,32,34-56,61-63,65-68,71,72,75,77,79-81,83,87-90} and including the pediatric and adolescent population (n = 40).^{26-30,35-39,43-45,47,51-53,55,56,59,61,62,64,66,68-70,72-76,79-83,85,89,90}

Table 1.

Article Characteristics.

Study design	Geographic setting	Institutional setting	Patient population
Randomized control trial	Urban^26-30,32	Academic primary care clinic²⁹	Pediatrics^26-30
	Not mentioned³¹	Safety-net urgent care clinic²⁷	Adults with depression³¹
		Community health center^30,31	Women with depression³²
		Women’s health clinic³²
		Multi-setting^26,28
Difference-in-difference/quasi-experimental	Urban³⁴	Academic primary care clinic³⁴	Adults³⁴
Difference-in-difference/quasi-experimental	Not mentioned³³	Integrated health system³³	Adults with predicted high utilization³³
Pre-post with control	Urban^35-37	Academic primary care clinic^35-37	Pediatrics^35-37
Observational studies (eg, pre-post, feasibility studies, pilots)	Urban^{38-56,62,63,65-68,71}	Academic primary care clinic^{38,41-44,47,48,51-54,56,59,63,65}	Pediatrics^{38,39,44,47,51,52,56,59,61,62,64,66,68-70}
	Multi-setting⁶¹	Academic women’s health clinic⁷¹	Adolescents^43,53
	Not mentioned^{57-60,64,69,70}	Private primary care clinic⁷⁰	Adults^{42,46,48,54,58,65,67}
		Integrated health system⁶⁰	Elderly Hispanic adults⁵⁷
		Community health center/federally qualified health center^{40,45,46,61,68,69}	Pregnant women⁴⁰
			Black women^49,50
			Women with depression⁷¹
		Academic-federally qualified health center^39,57,62,66	Multiple populations^45,55
		Unspecified primary care clinic^64,67	Not mentioned^41,60,63
		Multi-primary care setting^49,50,55,58	Not mentioned^41,60,63
Quality improvement	Urban^72,75,77,79	Student-run free clinic⁷⁸	Pediatrics^72-74
	Suburban⁷⁶	Federally qualified health center⁷⁴	Children with sickle cell disease⁷⁵
	Rural⁷³	Rural health clinic⁷³	Adults⁷⁸
	Not mentioned^74,78	Academic primary care clinic⁷⁹	Adult women⁷⁷
		Academic-community health center⁷²	Multiple populations^76,79
		Academic specialty clinic^75,77
		Integrated health system primary care clinic⁷⁶
Qualitative	Urban ^80,81,83,87	Academic primary care clinic^80,82,84,85	Pediatrics^80,81
	Not mentioned^82,84-86	Public primary care clinic⁸³	Adolescents⁸⁰
		Community health center^81,86	Adults⁸⁴
		Integrated healthcare system⁸⁷	Multiple populations^83,85
		Integrated healthcare system⁸⁷	Not mentioned^86,87
Case study	Urban^88,89	Academic primary care clinic⁸⁹	Pediatrics⁸⁹
	Multi-setting⁹⁰	Federally qualified health center⁸⁸	Adults⁸⁸
	Multi-setting⁹⁰	Multi-setting⁹⁰	Multiple populations⁹⁰

Workforce Models

All included studies were required to both identify by screening and respond to patients’ unmet social needs. To describe the structure of workforce models performing these activities, studies were first sorted by mode of administration used for screening. We found 37 studies used self-administered screening with patients,^{29,30,32,34,41,42-46,48,52-54,56,59,61,62,64-66,68,69,71-73,75-77,79,80-84,86,87} 24 studies used clinician-administered screening,^{26-28,31,33,35-40,47,49-51,57,60,63,74,78,85,88-90} 3 studies used both,^55,58,70 and 1 study did not mention the mode screening administration⁶⁷ (Figure 2). We then categorized the workforce associated with each screening administration type and the roles who responded to identified needs. The 65 studies reviewed used many different arrangements described below.

Figure 2.

Summary of types of workers deployed to identify and respond to unmet social needs.

In summary, for screening-related activities, 33 studies included the traditional healthcare workforce, such as clinical and front-desk staff,^{35-41,44-48,52,55,58,61,62,64,66,69,70,72,73,75-77,79,83,84,86,87,89,90} 21 included the social care workforce, including paid and volunteer staff,^{26-28,31,33,40,43,49-51,53,57,60,63,72,74,78,80,82,85,88} 7 included research staff,^{29,30,32,65,67,68,71} and 6 did not mention the specific type of worker.^{34,42,54,56,59,81} For assistance-related activities, 39 studies included the traditional healthcare workforce,^{29,30,35-48,53-56,59,61,62,64,66,68,69,72,73,75-77,79-81,86,87,89,90} 57 included the social care workforce,^{26-28,30,31,33-37,40-57,59-67,69,70,72,74-90} and 4 included research staff.^32,65,68,71

Screening and Responding to Unmet Needs

Self-administered

Of the 37 models that use self-administered screening, 21 used front desk staff or medical assistants to give patients a paper form or tablet to complete the screening questions at check-in or during registration, or had medical assistants distribute the screen while rooming a patient.^{41,42,45,46,48,52,61,62,64,66,72,73,75-77,79,83,84,86,87} In some models, after patients completed the screener, a medical assistant, nurse, or volunteer documented the screen in the electronic health record and/or transported the screen on paper to another provider.^{41,46,48,61,75,79,87} Two models included nurses in distributing self-administrated screening surveys.^44,73 In 3 articles, resource specialists used a web-based platform on laptops to administer an social needs screen that allowed patients to choose problems for assistance and referral agencies.^43,53,80 In 1 article, navigators administered the screening tool.⁸² Six studies used research assistants to provide patients with paper screening tools.^{29,30,32,65,68,71} Six articles did not report the workforce for self-administered screening.^{34,42,54,56,59,81}

In 10 of 37 models that used self-administered screening, the medical assistants, nurses, navigators, resource specialists, and research staff who provided patients with the screening form also reviewed the screen to provide assistance.^{32,43,53,65,68,69,71,73,80,82} While these staff were the first to provide assistance to patients, many still referred patients to other staff for additional assistance.^{43,53,65,68,69,80}

In the remaining 27 articles, the workforce that distributed the screen to the patient differed from the workforce that reviewed the screen and responded to the patient’s need(s). In 5 articles, a paid or volunteer social care worker was the first person to review a screen and provide assistance.^{34,41,46,83,84} In 22 articles a medical provider or resident was a primary reviewer and responder to the screen: in 1 article residents were the only workers reported to be involved in assisting patients in response to the screen²⁹; in 5 articles medical providers or residents were the primary responders but had the option of escalating to a social care worker (eg, care coordinator, patient navigator, health advocate, etc.)^{30,44,45,48,61}; and in 16 articles medical providers or residents only reviewed the screen and would always refer patients to a paid or volunteer social care worker to assist the patient with their needs.^{46,52,54,56,59,62,64,66,69,75-77,79,81,86,87} In 1 study, an interdisciplinary medical team reviewed the screen before referring patients to specific paid or volunteer social care staff.⁴²

Clinician-administered

We defined clinician-administered screening to include verbally asking questions from standardized paper forms, electronic-health record flowsheets, and through screening mnemonics. Of the 24 studies that included clinician-administered screening, 1 used medical providers to screen patients,³⁷ 7 used medical residents,^35-39,89,90 1 used a combination of clinical and social care staff (eg, nurse, social worker, medical assistant),⁴⁰ and 15 used paid social care staff (eg, case managers, community health workers, navigators) or volunteers.^{26-28,31,33,49-51,57,60,63,74,78,85,88}

In the 8 models using medical providers or residents, they either (1) assisted patients directly through community resource referrals,^38,39 (2) provided community resource referrals with an option to escalate to a social worker or an on-site medical legal partnership,^36,37,47,90 or (3) directly referred patients to social work or the onsite medical legal partnership without providing community resource information themselves.^35,89 In the 15 models that used social care staff or non-physician clinical staff to administer screenings, the same worker who conducted the screening was the same worker to provide initial assistance to patients,^{31,36,40,41,44,55,56,58,61,67} with 2 studies allowing for additional follow-up from separate student volunteers.^78,88

Hybrid models

Three studies described using both self-administered and clinician-administered screening.^55,58,70 For example, in 1 model, front desk staff provided paper screeners to patients for self-administration, and medical assistants offered screening verbally to accommodate patients with low literacy.⁵⁸

Response Activities

After screening, workers used a variety of options to respond to patients’ identified social needs (Figure 3). Six response activities and combinations were identified and inductively categorized according to intensity of activities by time and effort by personnel. The 6 activities from lowest to highest intensity were to: (1) refer patients to another clinic staff member for additional assistance without a defined approach for continued follow-up,^{35,42,52,54,56,59,62,64,66,72,76,77,79,86,87,89} (2) provide patients with resource lists for community-based organizations or government services organized by SDOH domain (eg, food or transportation),^{29,39,58,65,68,73,78} (3) provide patients with both resource lists and referral to other staff for more tailored support,^{30,34,44,45,47,48,61,69,75,81} (4) provide patients with both referral to other staff and immediate navigation services, such as directed referrals or support to complete applications for services with patients,^{36,37,40,55,70,90} (5) provide navigation support services,^{30,35-38,40-48,53,55,58,59,61,62,65-68,70,72,74,76-81,83,87-90} or (6) provide extended navigation services with follow-up of patients after the initial encounter to support follow-through.^{26-28,31-34,42,49-52,54,56,57,60,62-64,66,69,71,75,77,82,84-86,88}

Figure 3.

Variation in response activities and intensity of services provided.

Activities of the traditional clinical workforce such as physicians, nurses, and medical assistants tend to be less intensive activities (Figure 3). For example, medical providers and residents mostly provide referrals to other staff and/or resource lists.^{29,30,35,39,44,56,47,48,52,54,56,59,61,62,64,66,69,72,75-77,79,81,86,87,89} Similarly, nurses and medical assistants mainly referred to other staff of provided resource lists.^58,73,81 In contrast, the social care workforce from more well-established roles such as case managers, social workers, and community health workers, to the newer, specialized roles such as student volunteers and community resource specialists almost exclusively conducted activities related to navigation or extended navigation.^{26-28,30,31,33-37,40-67,69,70,72,74-90} Specifically, social workers were the most common workforce for navigation activities,^{30,41,42,44,47,55,59,61,62,66,72,76,77,79,87} and student volunteers were the most common workforce for extended navigation.^{26-28,34,42,51,52,56,57,63,64,77,84-86,88} In many models, navigation activities were conducted upon referral or escalation request from the clinical workforce that reviewed the initial screening.

Workforce Training

Study descriptions of training were summarized into 4 categories: in-person didactic training, online-training/video-based training, skills-based training, and experiential-learning. Training modes were either reported single component (n = 11, eg, only in-person training)^{29-31,39,44,46,48,57,60,72,75} or multi-component (n = 17, eg, in-person training and skill-based training).^{28,35-38,42,47,49,50,61,70,74,86,88-90} Of note, 37 studies did not explicitly report how staff were trained to implement the program.^{27,32-34,40,41,43,45,51-56,58,59,62-69,71,73,76-85,87}

Ten articles only reported using in-person didactic training^{29-31,39,44,46,48,57,72,75}; however, delivery could vary from 20-min informational meetings²⁹ to 3.5 hour lectures followed by discussion.³⁵ Four studies used online-learning or videos to supplement other modes of instruction.^36,37,61,70 Online-learning included modules on different SDOH domains such as food insecurity and interpersonal violence, screening practices, and motivational interviewing.^36,37 In-person videos included appropriate and inappropriate examples of screening and responding to social needs.⁶¹ Eight articles reported skill-based training components which consisted of instruction and practice beyond the intervention protocol such as motivational interviewing, cultural competency, trauma-informed, confidentiality, and professionalism.^{26,28,49,50,60,61,74,88} Eight studies reported experiential-learning components such as role plays, shadowing, advocacy opportunities, and immersion experiences to visit local community-based organizations.^{35,38,42,47,86,88-90}

Discussion

The purpose of this scoping review was to describe the workforce models implemented in ambulatory care settings to screen and respond to patients’ unmet social needs. In reviewing 65 peer-reviewed studies, we show the breath of traditional health care workers and social care workers deployed. Majority of screening-related activities were conducted by traditional healthcare staff, such as front-desk staff and medical assistants. Majority of assistance-related activities were conducted social care staff, such as social workers and student volunteers. We found wide variations by workforce in modes of screening administration, in the specific configurations of interprofessional teams, and in the intensity of responses to identified social needs. Practitioners and administrators can use this inventory to learn from models most relevant to their unique clinical context.

Our findings build on the instrumental 2019 NASEM report on Integrating Social Care into the Delivery of Healthcare which included a chapter on workforce.¹⁹ While the NASEM report outlines at a high-level the healthcare and social care workers that could be deployed, our paper systematically examines the existing literature to identify which workers are already screening for and responding to unmet social needs, the specific roles different workers play in interprofessional models, and how they are trained. Through an inductive approach, we created taxonomies for screening activities (clinician-administered, self-administered, and hybrid), response activities (referral to other staff, provision of a resource list, navigation support, and extended navigation support), and training activities (in-person didactic training, online or video training, skills-based training, and experiential-learning activities). This classification system could serve as a foundation from which to design comparative effectiveness research and rigorous clinical trials to examine workforce implementation.

While the vast majority of studies were conducted in academic settings, more research should be conducted to assess the appropriateness and feasibility of social needs interventions in federally qualified health centers and safety-net clinics that have greater resource constrains and higher rates of unmet needs.⁹¹ Similarly, a majority of studies were conducted with the general pediatric population, likely because the American Academy of Pediatrics has encouraged social needs provider screening since the early 2000s.¹¹ However, recent literature has demonstrated the need to focus on adults, especially vulnerable populations.^91-94

More rigorous study designs that test the implementation of different workforce models to identify and address social needs are needed. Only 7 articles reported using randomized control trial study designs while the majority were single-arm observational studies. While we found that social care staff frequently provided more intensive forms of assistance than traditional healthcare staff, little is known whether higher-touch interventions are more effective. While future studies must focus on comparative effectiveness and cost effectiveness of different delivery models,¹⁸ they should not forget to evaluate intervention development and implementation strategies related to workforce. For example, while a recent trial showed no difference in outcomes between providing patients with written resource materials and in-person navigation to address social risk,²⁷ further investigation of the navigators’ training, relatability, and communication skills could help explain the null findings.⁹⁵

Unfortunately, little is known how to train workers to conduct SDOH activities and which approaches are best fit for the different types of workers. The only studies that explicitly evaluated the training components of their models were with those that used pediatric residents,^35-39 possibly due to the growing emphasis on SDOH in post-graduate medical education.⁹⁶ Future efforts should test and optimize training materials and certification opportunities for non-physician workers to maximize efficacy.

Limitations

Our review has some limitations. First, we required clear reporting of a structured and standardized instrument or specified approach to social needs screening and this excluded many studies in which informal assessments and open-ended interviews were conducted by community health workers, social workers, and other professionals as part of routine care. Our rationale for requiring a standardized screening instrument was to have a clear path for response. Second, the restriction to peer-reviewed literature may have excluded models disseminated in the gray literature. Third, the anticipated variation in workforce personnel led us to search for models based on the type of intervention and not the workforce. As such, included studies may have underreported details about workforce. Future studies may consider surveying organizations directly to ensure comprehensive documentation of workforce components.

Conclusions

Despite a multi-sector push, there has still been poor uptake of social needs screening and response activities in healthcare settings, in part due to staffing limitations. Health systems must decide whether to hire new staff, onboard volunteers, repurpose existing staff into new roles, or add to the load of existing workers. Depending on the clinic’s context, each type of worker has unique advantages and disadvantages related to expertise, patient trust, reimbursement, and integration into existing clinical and information workflows.^97,98 This review demonstrates the breadth of feasible and replicable paths forward for building a workforce to integrate health and social care and identifies areas for future research.

Supplemental Material

sj-docx-1-jpc-10.1177_21501327211021021 – Supplemental material for Workforce Models to Screen for and Address Patients’ Unmet Social Needs in the Clinic Setting: A Scoping Review

Supplemental material, sj-docx-1-jpc-10.1177_21501327211021021 for Workforce Models to Screen for and Address Patients’ Unmet Social Needs in the Clinic Setting: A Scoping Review by Sahil Sandhu, Jacqueline Xu, Howard Eisenson and Janet Prvu Bettger in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We would like to thank Hannah Rozear for her support in developing our search strategy and advising our team on review management, and Dr. Sherryl Broverman for her thoughtful comments on the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Duke University Bass Connections in Global Health.

ORCID iDs

Sahil Sandhu

Jacqueline Xu

Supplemental Material

Supplemental material for this article is available online.

References

Braveman

Gottlieb

The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(suppl 2):19-31. doi:10.1177/00333549141291S206

Adler

Rehkopf

DH.

U.S. disparities in health: descriptions, causes, and mechanisms. Annu Rev Public Health. 2008;29:235-252. doi:10.1146/annurev.publhealth.29.020907.090852

WHO. Social Determinants of Health. WHO. Accessed July 14, 2019. http://www.who.int/social_determinants/en/

Healthy People 2030|health.gov. Social determinants of health. Accessed April 15, 2021. https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Kreuter

Thompson

McQueen

Garg

Addressing social needs in health care settings: evidence, challenges, and opportunities for public health. Annu Rev Public Health. 2021;42:329-344. doi:10.1146/annurev-publhealth-090419-102204

Alderwick

Gottlieb

LM.

Meanings and misunderstandings: a social determinants of health lexicon for health care systems. Milbank Q. 2019;97:407-419. doi:10.1111/1468-0009.12390

Czapp

Kovach

Poverty and Health – The Family Medicine Perspective (Position Paper). American Academy of Family Physicians; 2016.

Canadian Medical Association. Physicians and Health Equity: Opportunities in Practice. Health Care Transformation in Canada. Accessed May 25, 2021. https://nccdh.ca/resources/entry/physicians-and-health-equity

Institute of Medicine (U.S.), ed. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2. The National Academies Press; 2014.

10.

Daniel

Bornstein

Kane

, for the Health and Public Policy Committee of the American College of Physicians. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168:577. doi:10.7326/M17-2441

11.

Schor

, American Academy of Pediatrics Task Force on the Family. Family pediatrics: report of the task force on the family. Pediatrics. 2003;111:1541-1571.

12.

NCDHHS. Healthy opportunities. Accessed July 21, 2019. https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities

13.

Alley

Asomugha

Conway

Sanghavi

DM.

Accountable health communities—addressing social needs through Medicare and Medicaid. N Engl J Med. 2016;374:8-11.

14.

Henrikson

Blasi

Dorsey

, et al. Psychometric and pragmatic properties of social risk screening tools: a systematic review. Am J Prev Med. 2019;57:S13-S24. doi:10.1016/j.amepre.2019.07.012

15.

Morone

An integrative review of social determinants of health assessment and screening tools used in pediatrics. J Pediatr Nurs. 2017;37:22-28. doi:10.1016/j.pedn.2017.08.022

16.

Gottlieb

Fichtenberg

Alderwick

Adler

Social determinants of health: what’s a healthcare system to do?

J Healthc Manag. 2019;64:243-257. doi:10.1097/JHM-D-18-00160

17.

Gottlieb

Wing

Adler

NE.

A systematic review of interventions on patients’ social and economic needs. Am J Prev Med. 2017;53:719-729. doi:10.1016/j.amepre.2017.05.011

18.

Fichtenberg

Alley

Mistry

KB.

Improving social needs intervention research: key questions for advancing the field. Am J Prev Med. 2019;57:S47-S54. doi:10.1016/j.amepre.2019.07.018

19.

National Academies of Sciences, Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. National Academies Press; 2019.

20.

Arksey

O’Malley

Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19-32. doi:10.1080/1364557032000119616

21.

Tricco

Lillie

Zarin

, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467. doi:10.7326/M18-0850

22.

Clarivate Analytics. Endnote X7. Clarivate Analytics; 2013.

23.

Veritas Health Innovation. Covidence Systematic Review Software. Veritas Health Innovation; 2017.

24.

Machledt

Addressing the social determinants of health through Medicaid managed care. Issue Brief (Commonw Fund). 2017;2017:1-9.

25.

WHO. Human Resources for Health Action Framework. WHO. Accessed December 29, 2019. https://www.who.int/workforcealliance/knowledge/resources/haf/en/

26.

Gottlieb

Hessler

Long

, et al. Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial. JAMA Pediatr. 2016;170:e162521. doi:10.1001/jamapediatrics.2016.2521

27.

Pantell

Hessler

Long

, et al. Effects of in-person navigation to address family social needs on child health care utilization: a randomized clinical trial. JAMA Netw Open. 2020;3:e206445. doi:10.1001/jamanetworkopen.2020.6445

28.

Gottlieb

Adler

Wing

, et al. Effects of in-person assistance vs personalized written resources about social services on household social risks and child and caregiver health: a randomized clinical trial. JAMA Netw Open. 2020;3:e200701. doi:10.1001/jamanetworkopen.2020.0701

29.

Garg

Butz

Dworkin

Lewis

Thompson

Serwint

. Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE project. Pediatrics. 2007;120:547-558. doi:10.1542/peds.2007-0398

30.

Garg

Toy

Tripodis

Silverstein

Freeman

Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135:e296-e304. doi:10.1542/peds.2014-2888

31.

Waitzkin

Getrich

Heying

, et al. Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression. J Community Health. 2011;36:316-331. doi:10.1007/s10900-010-9313-y

32.

Poleshuck

Wittink

Crean

, et al. A comparative effectiveness trial of two patient-centered interventions for women with unmet social needs: personalized support for progress and enhanced screening and referral. J Womens Health (Larchmt). 2020;29:242-252. doi:10.1089/jwh.2018.7640

33.

Schickedanz

Sharp

, et al. Impact of social needs navigation on utilization among high utilizers in a large integrated health system: a quasi-experimental study. J Gen Intern Med. 2019;34:2382-2389. doi:10.1007/s11606-019-05123-2

34.

Berkowitz

Hulberg

Standish

Reznor

Atlas

SJ.

Addressing unmet basic resource needs as part of chronic cardiometabolic disease management. JAMA Intern Med. 2017;177:244. doi:10.1001/jamainternmed.2016.7691

35.

Klein

Kahn

Baker

Fink

Parrish

White

DC.

Training in social determinants of health in primary care: does it change resident behavior?

Acad Pediatr. 2011;11:387-393. doi:10.1016/j.acap.2011.04.004

36.

Klein

Alcamo

Beck

, et al. Can a video curriculum on the social determinants of health affect residents’ practice and families’ perceptions of care? Acad Pediatr. 2014;14:159-166. doi:10.1016/j.acap.2013.11.002

37.

O’Toole

Solan

Burkhardt

Klein

MD.

Watch and learn: an innovative video trigger curriculum to increase resident screening for social determinants of health. Clin Pediatr. 2013;52:344-350. doi:10.1177/0009922813475702

38.

Lax

Braganza

Patel

Three-tiered advocacy: using a longitudinal curriculum to teach pediatric residents advocacy on an individual, community, and legislative level. J Med Educ Curric Dev. 2019;6:238212051985930. doi:10.1177/2382120519859300

39.

Patel

Bathory

Scholnick

White-Davis

Choi

Braganza

Resident documentation of social determinants of health: effects of a teaching tool in the outpatient setting. Clin Pediatr. 2018;57:451-456. doi:10.1177/0009922817728697

40.

Harrison

Sidebottom

AC.

Systematic prenatal screening for psychosocial risks. J Health Care Poor Underserved. 2008;19:258-276. doi:10.1353/hpu.2008.0003

41.

Bleacher

Lyon

Mims

Cebuhar

Begum

The feasibility of screening for social determinants of health: seven lessons learned. Fam Pract Manag. 2019;26:13-19.

42.

Onyekere

Ross

Namba

Ross

Mann

BD.

Medical student volunteerism addresses patients’ social needs: a novel approach to patient-centered care. Ochsner J. 2016;16:45-49.

43.

Hassan

Scherer

Pikcilingis

, et al. Improving social determinants of health. Am J Prev Med. 2015;49:822-831. doi:10.1016/j.amepre.2015.04.023

44.

Selvaraj

Ruiz

Aschkenasy

, et al. Screening for toxic stress risk factors at well-child visits: the addressing social key questions for health study. J Pediatr. 2019;205:244-249.e4. doi:10.1016/j.jpeds.2018.09.004

45.

Byhoff

Garg

Pellicer

, et al. Provider and staff feedback on screening for social and behavioral determinants of health for pediatric patients. J Am Board Fam Med. 2019;32:297-306. doi:10.3122/jabfm.2019.03.180276

46.

Gold

Bunce

Cowburn

, et al. Adoption of social determinants of health EHR tools by community health centers. Ann Fam Med. 2018;16:399-407. doi:10.1370/afm.2275

47.

Beck

Henize

Kahn

Reiber

Young

Klein

MD.

Forging a pediatric primary care-community partnership to support food-insecure families. Pediatrics. 2014;134:e564-e571. doi:10.1542/peds.2013-3845

48.

Buitron de la Vega

Losi

Sprague Martinez

, et al. Implementing an EHR-based screening and referral system to address social determinants of health in primary care. Med Care. 2019;57:S133-S139. doi:10.1097/MLR.0000000000001029

49.

Clark

Baril

Kunicki

, et al. Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 breast and cervical cancer coalition women’s health demonstration project. J Womens Health (Larchmt). 2009;18:677-690. doi:10.1089/jwh.2008.0972

50.

Clark

Baril

Hall

, et al. Case management intervention in cervical cancer prevention: the Boston REACH coalition women’s health demonstration project. Prog Community Health Partnersh. 2011;5:235-247. doi:10.1353/cpr.2011.0034

51.

Garg

Sarkar

Marino

Onie

Solomon

BS.

Linking urban families to community resources in the context of pediatric primary care. Patient Educ Couns. 2010;79:251-254. doi:10.1016/j.pec.2009.10.011

52.

Uwemedimo

May

. Disparities in utilization of social determinants of health referrals among children in immigrant families. Front Pediatr. 2018;6:207. doi:10.3389/fped.2018.00207

53.

Kreatsoulas

Hassan

Subramanian

Fleegler

Social disparities among youth and the impact on their health. Adolesc Health Med Ther. 2015;6:37-45. doi:10.2147/AHMT.S64903

54.

Berkowitz

Hulberg

Hong

, et al. Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ Qual Saf. 2016;25:164-172. doi:10.1136/bmjqs-2015-004521

55.

O’Toole

Burkhardt

Solan

Vaughn

Klein

MD.

Resident confidence addressing social history: is it influenced by availability of social and legal resources?

Clin Pediatr. 2012;51:625-631. doi:10.1177/0009922812438081

56.

Garg

Marino

Vikani

Solomon

BS.

Addressing families’ unmet social needs within pediatric primary care: the health leads model. Clin Pediatr. 2012;51:1191-1193. doi:10.1177/0009922812437930

57.

Nguyen

Mosqueda

Angulo

, et al. A clinic-based pilot intervention to enhance diabetes management for elderly Hispanic patients. J Health Environ Educ. 2016;8:1-6. doi:10.18455/08001

58.

Page-Reeves

Kaufman

Bleecker

, et al. Addressing social determinants of health in a clinic setting: the WellRx pilot in Albuquerque, New Mexico. J Am Board Fam Med. 2016;29:414-418. doi:10.3122/jabfm.2016.03.150272

59.

Zielinski

Paradis

Herendeen

Barbel

The identification of psychosocial risk factors associated with child neglect using the WE-CARE screening tool in a high-risk population. J Pediatr Health Care. 2017;31:470-475. doi:10.1016/j.pedhc.2016.12.005

60.

Friedman

Toward addressing social determinants of health: a health care system strategy. Perm J. 2018;22:18-095. doi:10.7812/TPP/18-095

61.

Eismann

Theuerling

Maguire

Hente

Shapiro

RA.

Integration of the safe environment for every kid (SEEK) model across primary care settings. Clin Pediatr. 2019;58:166-176. doi:10.1177/0009922818809481

62.

Fiori

Patel

Sanderson

, et al. From policy statement to practice: integrating social needs screening and referral assistance with community health workers in an urban academic health center. J Prim Care Community Health. 2019;10:215013271989920. doi:10.1177/2150132719899207

63.

Bickerton

Siegart

Marquez

Medical students screen for social determinants of health: a service learning model to improve health equity. PRiMER. 2020;4:27. doi:10.22454/PRiMER.2020.225894

64.

Polk

Leifheit

Thornton

Solomon

DeCamp

LR.

Addressing the social needs of Spanish- and English-speaking families in pediatric primary care. Acad Pediatr. 2020;20:1170-1176. doi:10.1016/j.acap.2020.03.004

65.

Palakshappa

Benefield

Furgurson

, et al. Feasibility of mobile technology to identify and address patients’ unmet social needs in a primary care clinic. Popul Health Manag. Published online September 14, 2020. doi:10.1089/pop.2020.0059

66.

Fiori

Rehm

Sanderson

, et al. Integrating social needs screening and community health workers in primary care: the community linkage to care program. Clin Pediatr (Phila). 2020;59:547-556. doi:10.1177/0009922820908589

67.

Agarwal

Pirrie

Edwards

, et al. Legal needs of patients attending an urban family practice in Hamilton, Ontario, Canada: an observational study of a legal health clinic. BMC Fam Pract. 2020;21:267. doi:10.1186/s12875-020-01339-y

68.

Oldfield

Casey

DeCew

Morales

Olson

DP.

Screening for social determinants of health among children: patients’ preferences for receiving information to meet social needs and a comparison of screening instruments. Popul Health Manag. 2021;24:141-148. doi:10.1089/pop.2019.0211

69.

Messmer

Brochier

Joseph

Tripodis

Garg

Impact of an on-site versus remote patient navigator on pediatricians’ referrals and families’ receipt of resources for unmet social needs. J Prim Care Community Health. 2020;11:2150132720924252. doi:10.1177/2150132720924252

70.

Bittner

Thomas

Correa

Hatoun

Donahue

Vernacchio

A broad-based approach to social needs screening in a pediatric primary care network. Acad Pediatr. 2021;21:694-701. doi:10.1016/j.acap.2020.08.021

71.

Poleshuck

Wittink

Crean

, et al. Using patient engagement in the design and rationale of a trial for women with depression in obstetrics and gynecology practices. Contemp Clin Trials. 2015;43:83-92. doi:10.1016/j.cct.2015.04.010

72.

Berger-Jenkins

Monk

DʼOnfro

, et al. Screening for both child behavior and social determinants of health in pediatric primary care. J Dev Behav Pediatr. 2019;40:415-424. doi:10.1097/DBP.0000000000000676

73.

Higginbotham

Davis Crutcher

Karp

SM.

Screening for social determinants of health at well-child appointments: a quality improvement project. Nurs Clin North Am. 2019;54:141-148. doi:10.1016/j.cnur.2018.10.009

74.

Hensley

Joseph

Shah

O’Dea

Carameli

Addressing social determinants of health at a federally qualified health center. Int Public Health J. 2017;9:189.

75.

Power-Hays

Mensah

Sobota

Universal screening for social determinants of health in pediatric sickle cell disease: a quality-improvement initiative. Pediatr Blood Cancer. 2020;67:e28006. doi:10.1002/pbc.28006

76.

Sundar

Universal screening for social needs in a primary care clinic: a quality improvement approach using the your current life situation survey. Perm J. 2018;22:18-089. doi:10.7812/TPP/18-089

77.

Beavis

Sanneh

Stone

, et al. Basic social resource needs screening in the gynecologic oncology clinic: a quality improvement initiative. Am J Obstet Gynecol. 2020;223:735.e1-735.e14. doi:10.1016/j.ajog.2020.05.028

78.

Phan

RCV

Nguyen

Mader

. Rapid adoption of telehealth at an interprofessional student-run free clinic. PRiMER. 2020;4:23. doi:10.22454/PRiMER.2020.241619

79.

Bleacher

English

Leblanc

Dickinson

LM.

Associations between patients’ unmet social needs and self-reported health confidence at one primary care clinic. J Prim Care Community Health. 2020;11:2150132720921329. doi:10.1177/2150132720921329

80.

Wylie

Hassan

Krull

, et al. Assessing and referring adolescents’ health-related social problems: qualitative evaluation of a novel web-based approach. J Telemed Telecare. 2012;18:392-398. doi:10.1258/jtt.2012.120214

81.

Herrera

C-N

Brochier

Pellicer

Garg

Drainoni

M-L.

Implementing social determinants of health screening at community health centers: clinician and staff perspectives. J Prim Care Community Health. 2019;10:215013271988726. doi:10.1177/2150132719887260

82.

Emengo

Williams

Odusanya

, et al. Qualitative program evaluation of social determinants of health screening and referral program. PLoS One. 2020;15:e0242964. doi:10.1371/journal.pone.0242964

83.

Berry

Paul

Massar

Marcello

Krauskopf

Social needs screening and referral program at a large US public hospital system, 2017. Am J Public Health. 2020;110(suppl 2):S211-S214. doi:10.2105/AJPH.2020.305642

84.

Bryant

Walsh-Felz

Jacklitz

Lindberg

The impact of a community resource navigator program on patient trust. WMJ. 2020;119:190-193.

85.

Zhu

Ahluwalia

Laws

MB.

An evaluation of connect for health: a social referral program in RI. R I Med J (2013). 2020;103:65-69.

86.

Hsu

Cruz

Placzek

, et al. Patient perspectives on addressing social needs in primary care using a screening and resource referral intervention. J Gen Intern Med. 2020;35:481-489. doi:10.1007/s11606-019-05397-6

87.

Browne

Mccurley

Fung

Levy

Clark

Thorndike

AN.

Addressing social determinants of health identified by systematic screening in a Medicaid accountable care organization: a qualitative study. J Prim Care Community Health. 2021;12:215013272199365. doi:10.1177/2150132721993651

88.

Sandhu

Blanchard

, et al. A community resource navigator model: utilizing student volunteers to integrate health and social care in a community health center setting. Int J Integr Care. 2021;21:2. doi:10.5334/ijic.5501

89.

Klein

Beck

Henize

Parrish

Fink

Kahn

RS.

Doctors and lawyers collaborating to HeLP children—outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013;24:1063-1073. doi:10.1353/hpu.2013.0147

90.

Cohen

Fullerton

Retkin

, et al. Medical-legal partnership: collaborating with lawyers to identify and address health disparities. J Gen Intern Med. 2010;25(suppl 2):136-139. doi:10.1007/s11606-009-1239-7

91.

Research and Data. NACHC. Accessed July 29, 2020. http://www.nachc.org/research-and-data/

92.

Northwood

Ploeg

Markle-Reid

Sherifali

Integrative review of the social determinants of health in older adults with multimorbidity. J Adv Nurs. 2018;74:45-60. doi:10.1111/jan.13408

93.

Stafford

Wood

Tackling health disparities for people who are homeless? Start with social determinants. Int J Environ Res Public Health. 2017;14:1535. doi:10.3390/ijerph14121535

94.

Frier

Barnett

Devine

Barker

Understanding disability and the ‘social determinants of health’: how does disability affect peoples’ social determinants of health?

Disabil Rehabil. 2018;40:538-547. doi:10.1080/09638288.2016.1258090

95.

Garg

Byhoff

Wexler

MG.

Implementation considerations for social determinants of health screening and referral interventions. JAMA Netw Open. 2020;3:e200693. doi:10.1001/jamanetworkopen.2020.0693

96.

Hunter

Thomson

A scoping review of social determinants of health curricula in post-graduate medical education. Can Med Educ J. 2019;10:e61-e71.

97.

Fraze

Brewster

Lewis

Beidler

Murray

Colla

CH.

Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals. JAMA Netw Open. 2019;2:e1911514. doi:10.1001/jamanetworkopen.2019.11514

98.

Pescheny

Pappas

Randhawa

Facilitators and barriers of implementing and delivering social prescribing services: a systematic review. BMC Health Serv Res. 2018;18:86.

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