Expanding Implementation of a Social Determinants of Health Screening and Referral Program to Community-Based...

Social determinants of health (SDOH) are nonmedical factors that impact health and well-being. Primary care clinics have implemented screening for SDOH, but system-wide programs that reach multiple clinics remain limited in pediatric settings. This study evaluates the system-wide implementation of an SDOH screening and resource referral program at 8 community-based pediatric primary care clinics.

The SDOH program, which is built into the electronic health record (EHR), was piloted at a large, academic-based clinic. Implementation strategies from the pilot were used in this study. Implementation was evaluated with the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Data were collected from the EHR and surveys of the clinic practice managers.

During the implementation phase (July 1, 2023-December 31, 2023), all 8 community-based clinics supported adoption of the program. Five clinics identified champions, and 4 completed training and adopted quality assurance processes. During the maintenance phase (January 1, 2024-September 30, 2024), there were 14,590 well-child visits across all clinics, and 9818 (67.3%) completed screening. SDOH screening rates varied between clinics (21.6-95.9%). Clinics tended to maintain their screening rates over time. Exactly 2542 patient caregivers (25.9%) who completed screening were positive for at least 1 SDOH domain. Most clinics reported using a combination of resource lists (78%) or referrals (89%) to address positive screens. Exactly 67% of clinics reported the screening took less than 5 minutes per patient and addressing positive screens took 5 minutes or less.

The EHR-based SDOH screening and resource referral program was effectively expanded to multiple community-based pediatric primary care clinics, and screening rates were maintained over time.