Linking Underserved Patients to Social Services Using the SScAR Tool.

Abstract

The need to screen for social determinants of health (SDOH) is well documented in the literature. Addressing SDOH also requires linking patients to available social service resources. This Social Screen Assess and Refer (SScAR) Quality Improvement (QI) project purpose was threefold: (1) develop an agency specific tool to screen for SODH; (2) implement this tool in all new patient evaluations; and (3) provide referral to patients for necessary social services. The SScAR tool adapted questions from published screening tools and created new questions centered on available social services. A pilot study implemented the tool. Documentation of social needs before the pilot, SScAR utilization during the pilot, number of social needs, and referrals made were measured. Documentation of SDOH screening significantly improved with the tool (α .05, χ2(1) = 21.85, p < .001). Follow-through referral to specific social resources only increased by 5%. The SScAR is a feasible tool for identifying SDOH needs and creates a mechanism for linking patients with social services. Future studies must measure social service referrals, utilization of social services, and the resulting impact on specific health outcomes such as blood pressure, hemoglobin A1c, and cholesterol.