Optimizing the collection, integration, and use of health-related social needs data in the primary care setting: Recommendations derived from key interest-holders

Introduction/Objectives: Initiatives to identify and address health-related social needs (HRSN) are increasingly being implemented in clinical settings and have the potential to improve health outcomes. However, best practices for HRSN assessment and implementation are still needed. We gathered input to guide implementation of an HRSN initiative within adult primary care clinics at an academic health center.

Methods: We conducted 6 focus groups to explore multiple perspectives (ie, clinicians, staff, patients, and community organization representatives) on optimal approaches to collecting HRSN data, processes for providing support to patients, and strategies for incorporating HRSN data into clinical workflows. Data were qualitatively analyzed to address the study’s research questions, resulting in themes stratified by each interest-holder group.

Results: Themes centered on how the successful development and integration of HRSN initiatives require a multifaceted approach that includes dedicated staffing, standardized data collection, adequate resources for actionable support, streamlined EHR functionalities, and structured training for key personnel. HRSN initiatives must also consider local context, including the role of community organizations and their capacity to provide services that address social needs.

Conclusions: Findings highlight perspectives from key interest-holders for shaping HRSN initiatives within primary care settings. We provide recommendations for developing organizational capabilities to effectively address HRSN.