From mandate to meaning: A health equity implementation framework and knowledge-to-action-informed qualitative study of health-related social needs implementation

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.