Social determinants of health screening and intervention: A cystic fibrosis quality improvement process

Lower socioeconomic status is associated with significantly poorer outcomes in weight, lung function, and pulmonary exacerbation rates in people with cystic fibrosis (PwCF).

We aim to reduce health disparities and inequities faced by PwCF by screening for and addressing unmet social needs.

We aimed to increase routine social determinants of health (SDoH) screening of eligible PwCF from 0% to 95% and follow-up within 2 weeks for those PwCF who screened positive and requested assistance from 0% to 95% by December 31, 2021.

The Model for Improvement methodology was used. A process map and a simplified failure mode effects analysis chart were created for the screening and SDoH follow-up process. For those who screened positive for SDoH and requested assistance, follow-up contact was made to offer intervention.

Adult PwCF who had at least one UVA Clinic encounter in 2021 were screened for SDoH. The SDoH screening tool included eight domains: housing, food, transportation, utilities, health-care access, medication access, income/employment, and education. Follow-up was completed with all PwCF who screened positive for SDoH.

A total of 132 of 142 (93.0%) PwCF eligible for screening completed the SDoH screening. Of the PwCF who completed screening, 56 (42.4%) screened positive for SDoH. A follow-up rate of 100% was achieved in June 2021 and maintained through December 2021.

Implementing screening for SDOH and follow-up to mitigate social difficulties in adult PwCF at UVA was successful and could be reproduced at other CF care centers.