PULSE Toolkit

Social Needs Referrals in Primary Care: An Implementation Toolkit

As social risk screening increasingly becomes standard in primary care settings, upfront planning is required to connect patients to needed community resources, maintain up-to date information about available resources, and develop and adopt optimal workflows to support patients with getting their social needs met through community referrals.

This is a pragmatic, evidence-based toolkit intended to be used by clinic leaders, administrators, and staff to create or refine social needs referral-making and related activities in primary care settings. This toolkit provides an opportunity for clinic staff to learn and collaborate with each other. Drawing on results from prior research, the toolkit can help primary care teams make four key decisions to design social needs referral programs that are relevant to their unique contexts.

Social Needs Referrals in Primary Care: An Implementation Toolkit [PDF]

Implementation Materials

• Social Needs Referrals Orientation Template [PPT]
• Referral Goals Thermometer Template [Excel]
• Referral Outcomes Thermometer Template [Excel]
• PDSA Worksheet Template [PDF]
• Certificate of Recognition Template [PDF]

The toolkit was developed as a collaborative effort across four Implementation Science Centers in Cancer Control (ISC3) (Oregon Health & Science University and OCHIN BRIDGE-C2, Harvard ISCCCE, University of Washington OPTICC, and Washington University-ISC3) funded by the National Cancer Institute. Pilot testing of the toolkit was conducted in three diverse primary care clinics and further iterated based on pilot testing outcomes. The toolkit was also informed by the expertise of consulting partner, UCSF’s Social Interventions Research & Evaluation Network.

Suggested citation: Social Needs Referrals in Primary Care: An Implementation Toolkit. Oregon Health & Science University & OCHIN BRIDGE-C2, Washington University ISC3, Harvard University ISCCCE, Caring Health Center, University of Washington OPTICC; July 2024.

For questions related to this guide please contact: research@ochin.org.