Enhancing outcomes for geriatric patients with evaluation of the social determinants of health.

Unmet social needs lead to adverse health outcomes and contribute to health inequities. Efforts to screen for social determinants of health (SDOH) have occurred primarily within primary care. Here, we describe the feasibility of implementing a workflow for SDOH screening within 2 urology clinics in Charlotte, North Carolina. Our pilot was adapted from the WE CARE Model, which integrates a referral to community resources for patients identified with social needs and an optional followup with a navigator for additional assistance. Patients were screened with the validated Healthy Opportunities SDOH tool to assess food, housing, utilities, transportation and physical safety needs; 40 patients were screened at 2 urology clinics, totaling 80 patients. Surveys were sent to 16 clinicians and staff who participated in the pilot to assess feasibility of implementation. In all, 24/80 patients (30%) were screened for 1 or more social needs, with food and housing being the most frequent; 20/24 patients with social need (83%) successfully received a community resource guide, and 13 of those patients also requested a referral. All survey respondents either agreed or strongly agreed that screening was valuable and allowed them to better understand the needs of their patients. They also felt that understanding SDOH aligns with departmental goals and mission. Our results suggest that SDOH screening within a urological setting is feasible, and dedicated support staff should be available to ensure adequate followup for patients with unmet needs. Future work is needed to expand resources for patients and optimize workflow for clinicians.

Successfully incorporating social determinants of health (SDH) screening into clinic workflows can help care teams provide targeted care, appropriate referrals, and other interventions to address patients' social risk factors. However, integrating SDH screening into clinical routines is known to be challenging. To achieve widespread adoption of SDH screening, we need to better understand the factors that can facilitate or hinder implementation of effective, sustainable SDH processes. The authors interviewed 43 health care staff and professionals at 8 safety net community health center (CHC) organizations in 5 states across the United States; these CHCs had adopted electronic health record (EHR)-based SDH screening without any external implementation support. Interviewees included staff in administrative, quality improvement, informatics, front desk, and clinical roles (providers, nurses, behavioral health staff), and community health workers. Interviews focused on how each organization integrated EHR-based SDH screening into clinic workflows, and factors that affected adoption of this practice change. Factors that facilitated effective integration of EHR-based SDH screening were: (1) external incentives and motivators that prompted introduction of this screening (eg, grant requirements, encouragement from professional associations); (2) presence of an SDH screening advocate; and (3) maintaining flexibility with regard to workflow approaches to optimally align them with clinic needs, interests, and resources. Results suggest that it is possible to purposefully create an environment conducive to successfully implementing EHR-based SDH screening. Approaching the task of implementing SDH screening into clinic workflows as understanding the interplay of context-dependent factors, rather than following a step-by-step process, may be critical to success in primary care settings.

576 Background: Social determinants of health (SDoH) are associated with inferior health outcomes, morbidity, life expectancy, and healthcare expenses. Screening for SDoH is increasingly incorporated into routine clinical practice, however clinical decision support and resources addressing positive SDoH screening are less robust. As part of the ASCO PC4, we developed an electronic workflow that utilizes SDoH and depression screening tools with prepopulated referrals to assist the clinician in directing the referral to the most appropriate supportive service. Methods: Smilow Cancer Hospital ASCO Patient Centered Care Certification Implementation Team collaborated with our social work, psycho oncology, and Community Health Worker (CHW) to optimally screen and respond to patients who screened positive for SDoH or depression. A workflow was established using Welcome Web software in combination with Epic to transfer patient results collected in the waiting room via iPad to the patient’s medical record. Positive screening results trigger a best practice advisory when clinician opens chart. The alert links to a Smartset prepopulating an order to the appropriate resource for the reported need. Patients with transportation, food insecurity, or housing concerns were referred to Community Healthcare Worker. Social workers received referrals for patients with social connection concerns and PHQ-9 scores between 9-14. Patients with a PHQ-9 score of 15 and above were referred to the psycho-oncology team. A specialized workflow was created for any patient who responded positively to thoughts of self-harm. These patients received an immediate intervention and were screened using the Columbia Suicide Severity Screening Tool. Results: See table. Conclusions: Incorporating SDoH screening alongside clinical decision support and automated referrals was feasible. Technology enabled screening enhances efficiency and assists clinicians with direct referrals to the appropriate resource, while allowing resources to operate at the top of their licensure and enhance efficiency. Future Directions for Research: 1. Monitor emergency room utilization, admissions, and unplanned visits for patients receiving services from CHW, Social Work, and Psycho-oncology services. 2. Monitor work queue volumes to assess if directed referrals expedite response.[Table: see text]

Background: Social determinants of health have been well accepted as contributing to health outcomes. They are a vital aspect of health care delivery and must be a consideration, especially among free clinic populations. Social determinants of health have also become a required element of medical school curricula. The Student Outreach to Area Residents Student-Run Free Clinic based out of Northeast Ohio Medical University piloted a student-led program that implemented social determinants of health screening and community resource referral as a part of integrated health care delivery for all its patients. Methods: We described the development of a screening tool, protocol, and creation of community resource referral materials. We also described the tracking of patient-reported needs and mapping of location and accessibility of community resources. One hundred patients were surveyed through convenience sampling, and results were used for program improvement. Results/Conclusion: After collecting and analyzing survey results, it was found that the 2 most frequently requested determinants were mental health and utilities services, and the most available community resource was emergency food services. We also mapped these results by zip code and found gaps between need and distribution of services. We demonstrated the utility of mapping to identify points of improvement for the future. We also provided lessons learned related to effective social determinants of health screening, community resource referral, and overall program implementation in student-run free clinics. We further explained the benefits of including similar student-led programs as a way for students to gain practical experience related to social determinants of health.

Background: Social determinants of health (SDH) are known to negatively influence medical outcomes and are prevalent among people with diabetes, but systematic screening and use in routine diabetes care remains limited. Methods: We used quality improvement methodology to pilot a SDH screening protocol in our diabetes center in an underserved community, and included new adult diabetes patients of 2 providers from October to December 2019. We used a standardized SDH screen offered by the EPIC electronic health record system, which included 10 questions on transportation issues, food security, affordability of medication, housing stability, personal safety, and financial strain, among others. We performed iterative tests of the algorithm to improve reliability. Completion of the screen and responses were tracked electronically. Feasibility and acceptability were assessed with brief interviews of clinic staff and patients after each screen cycle. Results: Following implementation of the SDH screen protocol, 50 out of 53 (94%) eligible patients were screened (mean age 30, 53% female, 72% Medicaid). Patients who did not complete screens refused due to privacy concerns or were unable to respond due to developmental delay. One-third of patients (n= 17, 32%) reported at least 1 SDH. The most common SDH noted were lack of transportation to visits and food insecurity. Participants who reported SDH and desired assistance were referred to a care coordinator trained to address social needs. In brief post-screen interviews, staff and patients alike expressed high feasibility and acceptability of the SDH screen. Conclusions: Screening for SDH is important, uncovering social needs that are relevant and impactful for diabetes outcomes, while still maintaining high staff and patient acceptability. Given potential for linkage to future payment, SDH screening should be incorporated into routine diabetes care. Disclosure A. Manavalan: None. D. Lee: None. A. Jang: None. S. Agarwal: None.

Introduction: Social determinants of health (SDoH) have been extensively studied in adult populations, revealing strong associations between adverse health outcomes and factors such as race, ethnicity, and socioeconomic status. Similar disparities are observed in pediatric populations, though data in this domain remain limited. In response, the University of Chicago has established a goal of screening at least 75% of all patients and their families for social needs to better understand and address these disparities especially given its high-risk catchment area. However, the Pediatric Hematology and Oncology (Peds H/O) clinic currently underperforms relative to this institutional benchmark in both survey completion and data integration within the Epic electronic health record system. Methods: Prior to this study, a Social Determinants of Health screening tool was developed to assess six health-related social needs (HRSNs) specifically for pediatric patients. While originally designed for integration into medical assistant or nursing workflows, the Peds H/O clinic lacks medical assistant staffing due to the specialized nature of its patient care model. Consequently, this quality improvement initiative will shift data entry responsibilities to providers—including attendings, advanced practice nurses (APNs), and fellows—who will be trained in proper data input procedures. Post-intervention tracking will evaluate improvements in survey completion rates and the impact on care coordination. In parallel, social work contact hours and consultation instances will be recorded in a shared Excel database, allowing for detailed tracking of consult reasons, interventions, and associated patient demographics. Medical record number (MRN) data will be used to identify patterns in service utilization and inform timing of interventions. The combined dataset will be analyzed to identify periods of elevated resource utilization throughout oncology treatment and to evaluate patterns in resource allocation associated with social determinants of health, including socioeconomic status, educational attainment, and geographic indicators such as zip code. Results: Results will be reported following survey data extraction and analysis. Conclusions: Through this integrated analysis of SDoH screening results, demographic characteristics, and social work engagement, the project aims to elucidate common risk factors and resource needs among pediatric hematology and oncology patients. Ultimately, the goal is to establish a data-informed framework for early identification and proactive intervention for high-risk populations, thereby enhancing health equity and outcomes. Citation Format: Karyssa S. Knopoff, Allison Bartlett, Loren Saulsberry, Lindsay Schwartz. Improving social determinants of health (SDoH) screening and intervention in a pediatric hematology/oncology clinic: A quality improvement initiative [abstract]. In: Proceedings of the 18th AACR Conference on the Science of Cancer Health Disparities; 2025 Sep 18-21; Baltimore, MD. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2025;34(9 Suppl):Abstract nr A010.

Social determinants of health (SDoH) have been associated with disparate outcomes among those with metabolic dysfunction-associated steatotic liver disease (MASLD) and its risk factors. To address SDoH among this population, real-time SDoH screening in clinical settings is required, yet optimal screening methods are unclear. We performed a scoping review to describe the current literature on SDoH screening conducted in the clinical setting among individuals with MASLD and MASLD risk factors. Through a systematic literature search of MEDLINE, Embase, and CINAHL Complete databases through 7/2023, we identified studies with clinic-based SDoH screening among individuals with or at risk for MASLD that reported pertinent clinical outcomes including change in MASLD risk factors like diabetes and hypertension. Ten studies (8 manuscripts, 2 abstracts) met inclusion criteria involving 148,151 patients: 89,408 with diabetes and 25,539 with hypertension. Screening was primarily completed in primary care clinics, and a variety of screening tools were used. The most commonly collected SDoH were financial stability, healthcare access, food insecurity and transportation. Associations between clinical outcomes and SDoH varied; overall, higher SDoH burden was associated with poorer outcomes including elevated blood pressure and hemoglobin A1c. Despite numerous epidemiologic studies showing associations between clinical outcomes and SDoH, and guidelines recommending SDoH screening, few studies describe in-clinic SDoH screening among individuals with MASLD risk factors and none among patients with MASLD. Future research should prioritize real-time, comprehensive assessments of SDoH, particularly among patients at risk for and with MASLD, to mitigate disease progression and reduce MASLD health disparities.

Social determinants of health (SDH) contribute to nearly 50% of health outcomes; however, SDH data collection is inconsistent in clinical practice. This study used mixed methods to evaluate health care professionals' perceptions of universal SDH screening at an academic medical center by surveying physicians, advanced practice providers, nurses, social workers, case managers, pharmacists, and administrators. An electronic survey assessed SDH screening practices, prioritization of SDH domains, disciplines to perform screening, and attitudes and barriers to universal screening. Likert-scale responses were dichotomized and compared disciplines with proportions tests. Qualitative interviews identified themes and elaborated survey findings. Participant discipline was the primary predictor variable. Of 193 survey participants (62.5% response rate), most were physicians (31%) or social workers (22%). Participants overwhelmingly reported using SDH information in patient care (93%), and social workers as the most appropriate role for screening (95%). Most respondents (75%) believed health literacy is important, but 40% reported routine assessment. Housing status (73% vs. 53%) and financial strain (62% vs. 48%) followed similar patterns. SDH screening barriers included lacking resources to address identified needs (51%), time to ask (45%), support staff to ask (33%), and training in responding to identified needs (28%). Social workers cited barriers less often than non-social workers (P < 0.001). Qualitative interviews (n = 16) supported survey findings and described barriers including lack of time, resources, standardized approaches, and professional burnout. Health care professionals support universal SDH screening while highlighting the need to address implementation barriers. Strategies should leverage social work expertise and optimize SDH data accessibility for all providers.

Health systems are increasingly investing in social determinants of health (SDoH), but there is limited research on how such efforts impact health care resource use. This study presents pilot work on an SDoH screening and referral platform recently implemented in South Carolina's largest private nonprofit health system. To assess the feasibility and sustainability of SDoH screening and SDoH-related referrals in a large health system and examine how they affect health resource use. Observational study using electronic medical records and SDoH screening data from June 1, 2019 to December 31, 2020. Patients (18 y+) engaged in community health, inpatient case management, or ambulatory care and condition management programs. We describe the use of SDoH screening by providers (community health workers, nurse case managers, and social workers) and SDoH referral volumes among patients. We use multivariate analyses to predict changes in emergency department visits, inpatient admission s (length of stay and volume), and primary care visits from referral volume, SDoH screening question responses, and patient characteristics (eg, comorbidities). Of 2687 patients, 662 (24.6%) screened positive for 1 or more SDoH domains. SDoH screening performance remained consistent among providers over time. Six hundred fifty-eight (24.5%) patients received SDoH referrals. Patients receiving an increasing volume of referrals had decreasing primary care visits but their comorbidities moderated this effect. The study provides initial descriptive information on SDoH needs, implementation of referrals and resource use, guiding SDoH screening implementation in population health, and care management programs.

ObjectivesTo estimate the prevalence and distribution of social needs among obstetric triage patients at ChristianaCare; examine associations with patient characteristics and insurance status; and identify implementation and policy implications for integrating social determinants of health (SDOH) screening into obstetric care in Delaware.MethodsWe conducted cross-sectional SDOH screening among patients aged ≥18 years presenting to the obstetric triage unit at Christiana Hospital (November 2019–February 2020). An 11-item tool covering 10 social-need domains was administered; 326 (82%) patients participated, and 317 unique patients were analyzed. Descriptive statistics estimated social-need prevalence. Age-adjusted logistic regression assessed associations of race/ethnicity and insurance (Medicaid/self-pay vs other) with each domain and with cumulative needs. Screeners completed brief debriefs on feasibility and workflow.ResultsParticipants had a mean age of 30.2 years; 49.5% were White, 38.4% Black, and 10.7% Hispanic/Latine; 39.1% had Medicaid or were self-pay. Overall, 46.1% reported ≥1 social need and 7.0% reported ≥4 needs. Financial strain, food insecurity, and housing and transportation challenges were among the most frequently endorsed domains. Black and Hispanic/Latine patients and those with Medicaid or self-pay coverage experienced significantly higher odds of multiple social-need domains and ≥4 needs (all p<0.05). Screening was feasible and acceptable but required attention to privacy, timing, and referral pathways.ConclusionsNearly half of obstetric triage patients reported unmet social needs, with marked inequities by race/ethnicity and insurance. Triage-based SDOH screening is feasible and can connect patients to social, legal, and community supports. Public Health and Policy Implications: Integrating SDOH and food insecurity screening into obstetric triage, linking patients to social, legal, and Food is Medicine supports, and advancing upstream policies on wages, housing, and racism may narrow racial and socioeconomic gaps in maternal and infant outcomes and advance reproductive justice in Delaware.

Background: Social Determinants of Health (SDOH) are strongly associated with outcomes for patients with diabetes. Incorporating widespread clinic SDOH screening programs is challenging. We aim to demonstrate the use of Quality Improvement (QI) interventions in expanding SDOH screening practices across 5 pediatric and 1 adult diabetes center in the T1D Exchange Improvement Collaborative (T1DX-QI). Method: The centers applied QI principles to design iterative plan-do-study-act (PDSA) cycles to develop and expand interventions to improve screening rates. The interventions include staff training, creating a social risk index, using EHR patient-facing portal, partnership with community organizations, referral to clinic, and community resources. The centers shared monthly aggregate data with the coordinating center. Statistical Process Control charts were created and analyzed for significant shifts. Result: All centers successfully implemented SDOH screening, and improvement ranged from 41% to 68%. Overall screening increased from baseline by 56% in 24 months. Disclosure O.Odugbesan: None. E.J.Hess: None. N.Rioles: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. T.Wright: None. N.Yayah jones: Consultant; Medtronic. M.Gallagher: None. J.Ilkowitz: None. S.A.Dei-tutu: None. E.L.Dewit: None. R.Izquierdo: None. M.Desimone: None.

Introduction Delays to surgery in the treatment of breast cancer can lead to worse disease specific mortality and overall survival. Previous work has shown a woman’s time to surgical treatment is influenced by income, which may be secondary to social determinants of health (SDOH) including health literacy, safety, stress, access to health care and transportation, housing, and ability to pay utilities. This study sought to evaluate a screening process for SDOH to assess and address barriers to care for women newly diagnosed with breast cancer. Methods A SDOH screening tool consisting of 7 yes/no questions was developed and used by trained breast oncology nurses via phone call made to all new patients prior to their first visit. Based on patient response, patients are provided with community resources or referred to the hospital social work team. Primary outcome included the SDOH screening results, and secondary outcome included time to surgery. Results 118 patients were screened, of which 60 patients had surgery as their first treatment and were included in this analysis. Twenty-seven patients screened positive for SDOH need. Ten patients reported &amp;gt;3 SDOH concerns and were referred to social work. The most common concerns were food insecurity and trouble paying utilities. Of the 27 patients who screened positively, 18 identified as Black or African American, 3 were Hispanic, 1 Asian and 5 White. The mean household income for these patients based on their reported zip codes was $55,615.78. Average time to surgery for patients with a positive SDOH screen was 37.7 days and negative SDOH screen was 42 days. For patients with a positive SDOH screen, those with 2 or fewer SDOH needs had an average time to surgery of 41.9 days and those with 3 or more SDOH needs had an average 30.6 days until surgery. Discussion Patients who screened positive for SDOH need and were provided resources had a faster time to surgery than patients who initially screened negative for SDOH. Patients referred to social work had the fastest time to surgery. Early identification of SDOH is necessary for all patients to improve equity and outcomes in breast cancer treatment. Citation Format: Hilary Tingley, Madeline McIntosh, McKenzie Klee, Margaret Gladman, Alison Coogan, Andrea Madrigrano. Using Social Determinants of Health to Improve Surgical Delays for Breast Cancer Patients at Rush University Cancer Center [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-09-08.

Piloting a prenatal care smartphone application and care navigation intervention at a federally qualified health center

Outpatient screening for social determinants of health (SDH) improves patient access to resources. However, no studies have examined if and how inpatient pediatric providers perform SDH screening. We aimed to identify inpatient pediatric provider screening practices for SDH, barriers to screening, and the acceptability of screening for hospitalized patients. We conducted a multicenter descriptive study at 4 children's hospitals surveying inpatient hospitalists and nurses on the general wards about their SDH screening practices. A survey instrument was developed on the basis of literature pertaining to SDH, content expert review, cognitive interviews, and survey piloting. Descriptive statistics and logistic regression analyses are reported. Results from 146 hospitalists and 227 nurses were analyzed (58% and 26% response rate, respectively). Twenty-nine percent of hospitalists and 41% of nurses reported screening for ≥1 SDH frequently or with every hospitalized patient. Only 26% of hospitalists reported consistently communicating SDH needs with primary care providers. Most respondents (97% of hospitalists and 65% of nurses) reported they do not use a specific screening tool, and only 34% of hospitalists and 32% of nurses reported feeling competent screening for SDH. Lack of time, resources, and a standardized inpatient screening tool were reported as barriers to screening. Hospitalization provides an opportunity for SDH screening and connecting patients to resources; however, a minority of pediatric providers currently report screening. Professional development activities training inpatient providers in SDH screening, using a screening instrument, and communicating identified needs to primary care providers may improve the effectiveness of SDH screening in the hospital.

Addressing Social Determinants of Mental Health in Pediatrics During the Coronavirus Disease 2019 Pandemic.