Peer-Reviewed Articles
Awareness / Screening Studies
Performance of 2-Stage Health-Related Social Needs Screening Using Area-Level Measure Vest JR, Harle CA, Blackburn J | American Journal of Managed Care
Although a 2-stage approach based on area-level socioeconomic measures can reduce the number of patients requiring individual-level HRSN screening, large percentages of patients in need would be missed.
Comparison of the Performance of Three Health Related Social Needs Screening Tools Fennelly KM, Calvo-Friedman A, Clapp J, et al. | Journal of the American Board of Family Medicine
Despite differences in question phrasing and response options, all 3 screeners (a tool developed by NYC Health + Hospitals, a version of the AHC tool, and WellRx) performed similarly.
Validation of an Electronic Health Record Algorithm for Identifying Housing-Related Needs in a Safety-Net Health System McCann NC, de Cuba SE, Hofman M, et al. | Health Services Research
HRSN screening yielded the highest single-element sensitivity but missed 40% of those with verified housing-related needs. An algorithm leveraging structured data elements tailored to local context had moderate sensitivity and high specificity, identifying more housing-related needs than diagnostic codes alone.
Merging Law and Medicine: Patient Attitudes About and Experiences with Social Needs Screening and Medical-Legal Partnerships in Primary Care Graham JD, Kraschnewski JL, Allen SI, Makhlouf M, Llavona-Ortiz J, Calo WA | Journal of Primary Care & Community Health
This paper reports on the social needs screening experiences/preferences and interest in MLPs among a nationally representative sample of 500 U.S. adults who had visited a primary care provider in the past year.
Health Care Providers' Perceptions of Unmet Needs Among African American Cancer Caregivers: Qualitative Investigation Among US Medical Professionals Love B, Dermid G, Upshaw S, Stark A | JMIR Cancer
Providers identified three types of unmet needs among African American cancer caregivers: practical needs, social-emotional needs, and cultural barriers and made recommendations such as: (1) formal acknowledgment and compensation of caregiving as essential work; (2) integration of caregivers as equal members of multidisciplinary care teams; (3) recognition and leveraging of cultural assets, including strong family networks, community values, and faith-based support.
The First Step Is Knowing: Quantifying Social Need Through Screening in a Pediatric Surgery Clinic Rollins PD, King S, Majcher A, Hughes BD, Newman EA, Perone EE | Journal of Surgical Research
One in five pediatric surgery clinic outpatients (241 of 1410, 17.1%) screened positive for at least one unmet social need. The authors conclude that pediatric surgery patients experience high rates of unmet social need and that standardized screening is feasible in an ambulatory surgical care setting.
Socioeconomic and Psychosocial Needs in Pediatric Infectious Diseases Outpatient Settings Day ME, Choony C, Duan Q, et al. | Clinical Pediatrics
Caregivers reported anxiety (70%), depression (20%), and food insecurity (10%), with 20% reporting ≥4 ACEs. Median Social Deprivation Index (SDI) scores were twice as high for children with reported food insecurity (0.61) compared to those without food insecurity (0.61 vs 0.28, P < .001).
Characterizing Intersecting Social Determinants of Health During Pregnancy: A Descriptive Cross-Sectional Analysis from a Northern New England Health System Dev A, Allen SE, Cass I, Canavan CR, Velmineti V, Goodman DJ | Frontiers in Medicine
Social isolation emerged as a significant concern for non-urban pregnant women who had no other reported social determinants.
Help-Seeking Patterns Among Socially Isolated Patients in Primary Care Patel MR, Leung CW, Saksena R, Hao W | J Gen Intern Med
Healthcare systems should implement proactive strategies to capture patients with social isolation but no material hardships needs since existing screening and referral approaches may overlook patients who appear demographically advantaged.
Assistance
Effectiveness Studies
Health-Related Social Needs and Health Care Utilization in the Accountable Health Communities Model Sidebottom AC, Martins S, Vacquier MC, Dechaine C, Behrens D | JAMA Network Open
Resolution of individual HRSNs was not associated with subsequent reductions in inpatient admission or ED visits. Resolution of food needs was associated with a small increase in inpatient admissions. This is the first study that we know of that directly examines the association between needs resolution and health care utilization in the AHC model. See accompanying commentary here
The Veggie Vouchers Intervention to Promote SNAP Fruit and Vegetable Incentive Program Use for Families with Food Insecurity: A Single-Arm Feasibility Study Adams EL, Savidge M, Reesor-Oyer L, et al. | Pilot and Feasibility Studies
After brief education about the program by pediatricians, 70% of caregivers used a free trial. At the end of the free trial, only 20% used the SNAP F&V incentive (50% or more discount on fruits and vegetables).
Implementation and Outcomes of a Pharmacist-Led Social Determinants of Health Screening and Intervention Program in an Integrated Health System Specialty Pharmacy Model Lakada I, Stutsky M, Huynh C, Periyasamy S, Idusuyi A | Journal of the American Pharmacists Association
This small pilot study found that a pharmacist-led SDOH program had high acceptance rate (80%) and patients reported relatively high perceived benefit (63%). Patients receiving interventions demonstrated clinical outcomes improvements, including a mean RAPID3 score reduction of 3 points (range: 1.3-27.3) and mean LDL reduction of 29.75 mg/dL (range: 44-137) for RA and hyperlipidemia.
Five-Year Outcomes of a CHW-Driven Maternal-Infant Health Model through a County Health Department in a Medically Underserved Region Gonzalvo JD, Chaudhry F, Burney HN, et al. | Journal of Health Care for the Poor and Underserved
This Medicaid-covered, CHW-driven Pre to 3 Program provided free, hands-on support for infants, parents, and families from the first trimester of pregnancy until the child's third birthday and improved breastfeeding initiation, safe sleep practices, adequate prenatal care, child vaccination rates, food security, housing stability, and employment status.
Improving Vaccination Rates by Connecting Families to Community Resources Arthur J, Terhaar AS, Huang J, LaBarge G, Barnidge E | Clinical pediatrics
A social needs screening and navigation intervention in a Midwestern, low-income, pediatric clinic improved immunization adherence in intervention compared to control group participants.
Connected Care for Older Adults: A Pilot Intervention Engaging Community Health Workers to Advance Age-Friendly Care in Rural Oregon De Lima B, Miller L, Foster E, Ready J, Eckstrom E | Journal of the American Geriatrics Society
Embedding community health workers (CHWs) into rural primary care teams to assist with implementation of the 4Ms of the Age-Friendly Health System made a positive difference for 95% of responding patients (n = 120), and 100% of responding providers (n = 19) were "very satisfied" with the program. Early data suggest this program also may reduce health care utilization. Clinicians cited the CHWs' ability to support resource connections, address social isolation and social needs, provide regular check-ins, and help to get patients and families engaged in care as positive components of the model.
Implementation Studies
An Introduction to North Carolina Integrated Care for Kids (NC InCK): A Model to Support Whole-Child Health Wong CA, Allin S, Swanson C, et al. | Healthcare
This study describes the design of the North Carolina Integrated Care for Kids (NC InCK) model. A model collaboratively developed by healthcare systems, the state Medicaid agency, managed care organizations, child-serving organizations, and families. It integrates care using three key approaches: Risk Stratification Algorithm, Family-Centered Care Management and Alternative Payment Model.
Food Insecurity Screening and Intervention Strategies in Pediatric Primary Care Practices: A Mixed Methods Study Suarez L, James G, Montez K, et al. | Academic Pediatrics
This study describes and identifies barriers and facilitators to FI screening, intervention, and documentation processes in 27 clinics across the nation.
From Mandate to Meaning: A Health Equity Implementation Framework and Knowledge-to-Action-Informed Qualitative Study of Health-Related Social Needs Implementation Zimmer RP, Singletary C, Aguilar A, et al. | Health Services Insights
Frontline staff (including clinicians, navigators, and CHWs) reported disjointed workflows, unclear referral roles, and limited communication related to HRSN implementation. Suggested improvement strategies included role-specific training, participatory design, improved integration of CHWs into care teams, feedback loops, and locally adapted referral protocols.
Navigating the Journey from Hospital to Help: Family Perspectives on Overcoming Barriers to Connecting with Resources to Address Social Needs Kovaric K, Pham Q, Earp A, Wellman N | Hospital Pediatrics
Barriers experienced by 25 caregivers of hospitalized children included feeling overwhelmed, slow resource access, poor communication, and referrals and resources that do not match families' needs. Families desired continued support after hospital discharge to overcome barriers to resource connection, particularly for Spanish-speaking caregivers.
Evaluation Strategies
Evolving Food as Medicine Programs to Advance Health Equity: Insights from Two Decades of Practice Thomas O, Gago CM, Egan KA, Sheward R, Burt KG | Current Opinion in Pediatrics
This case study describes equity-centered evaluation strategies used by a food as medicine initiative Nourishing Our Community Program (NoC)at Boston Medical Center (BMC). Also, it provides a replicable framework for health systems.
Commentaries & Blogs
Integration of Food and Nutrition into Oncology Care: Proceedings of the Food is Medicine in Oncology Care Symposium Raza S, Garfield KM, Sullivan KR, et al. | Cancer
University of San Francisco California