Social Determinants Of Health Research Articles

Characteristics of Patients Utilizing Telemedicine in Hand and Upper-Extremity Surgery.

The impact of social determinants of health on patients' access to medical care and health outcomes is increasingly recognized. Telemedicine's rapid and widespread adoption altered the delivery of care. This study describes the characteristics of patients undergoing telemedicine visits with hand surgeons, without COVID-19 pandemic-related restrictions. All telemedicine encounters for 4 hand surgeons at a single institution between September 2022 and September 2023 were retrospectively reviewed. Patient demographics were recorded as well as the encounter type. The distance of the patients' residential address and the area deprivation index (ADI) were recorded. Sixty patient encounters were recorded. Forty-seven percent were male and 53% were female, 5 (8.3%) were new patients, 44 (73.3%) were established patients, and 11 (18.3%) were postoperative. The mean age was 43, and the mean and median distances from the clinic were 72 and 18 miles, respectively. Forty-three patients (72%) were from high ADI residences. Upon comparison of low ADI (0-50th percentile) and high ADI (50th-100th percentile) patients, no statistically significant differences in age, sex, distance from clinic, or encounter type were found. Telemedicine in hand surgery at this single institution is most frequently used for follow-up encounter types in patients living in high ADI communities, far from clinic sites. Low or high ADI did not correlate with seasonal changes in the use of telemedicine, encounter type, or patient demographics. Telemedicine may improve patient access to hand surgery follow-up care. This may particularly benefit patients facing geographic and economic challenges to healthcare access. Prognostic Level IV.

Evolving trends in oral cancer burden in Europe: a systematic review

IntroductionOral cavity cancer (OCC), primarily oral squamous cell carcinoma (OSCC), is a growing concern in Europe, particularly among younger populations. Preventable lifestyle factors and social determinants of health contribute significantly to the disease burden. Limited access to healthcare and delayed diagnoses further complicate treatment and reduce survival rates.MethodsThis systematic literature review adhered to PRISMA guidelines to explore trends in OSCC epidemiology, etiology, diagnosis, treatment, and survival across Europe. A comprehensive search strategy using PubMed, GLOBOCAN data, and the EUROCARE-5 study identified relevant articles focusing on human populations in Europe with a primary interest in OSCC epidemiology. Only peer-reviewed publications in English with full-text access were included.ResultsThis study investigated the burden of OSCC across Europe, revealing variations in incidence, mortality, and prognosis. Eastern and Central Europe displayed the highest burden. Males exhibited a significantly higher risk compared to females. Age-related disparities existed in life expectancy and time to achieve favorable outcomes. HPV emerged as a growing risk factor for oropharyngeal cancer. Public health strategies should target modifiable risk factors and improve early detection.ConclusionThis review reveals concerning disparities in European OSCC. Region, sex, and age all influence burden and prognosis. Future research should focus on controlling risk factors and personalized medicine to optimize treatment. This will lead to a Europe with reduced OSCC incidence and demonstrably better patient outcomes.

Comparing the Health Status of Immigrant and New Zealand-Born Older Adults in Aotearoa New Zealand: The Role of Socioeconomic Position.

The study investigated the health status of older migrants relative to their New Zealand-born peers. We adopted a holistic view of health (physical, mental, and social) and a structural approach to health disparities based on migrant status and socioeconomic position. Using case-control matching based on age, gender, and education, the health status of 357 older migrants and 357 New Zealand-born older adults was compared. Older migrants reported significantly poorer social health. Health inequities were patterned by socioeconomic status. Working class older migrants had significantly poorer physical, mental, and social health than their New Zealand-born peers. Inequities in social wellbeing persisted even at the upper end of the social gradient. Migrant background is an important social determinant of health in older age. The reduced social wellbeing of economically advantaged migrants highlights vulnerabilities regardless of socioeconomic position and the need for targeted social policies.

Correlates of Professional Breastfeeding Perceived Role, Perceived Influence, and Confidence in Providing Lactation Support Among Registered Dietitians and Registered Nurses

Lactation support from health professionals is a crucial social determinant of health. Registered dietitians (RDs) and registered nurses (RNs) can play an important role in supporting breastfeeding, yet most have minimal formal lactation education and training. This study seeks to explore the correlates of professional breastfeeding perceived role, perceived influence, and confidence in providing lactation support among RDs and RNs. Using a cross-sectional design, a convenience sample of 111 credentialed providers completed an online survey assessing their breastfeeding-related training, experiences, knowledge, attitudes, and practices. We also examined perceptions of social support, intentions for future breastfeeding, professional roles, and confidence in lactation support. We tested for relationships between variables using chi-square, Fisher’s exact, and Mann–Whitney U tests and identified which correlates were associated with the dependent variables using bivariate logistic regression. Respondents who were breastfed as infants were 3.4 times more likely to agree that it is their responsibility to highlight health problems associated with infant formula when giving breastfeeding advice (p = 0.009). Those agreeing that people around them support breastfeeding were 8.0 times more likely to believe they can influence a woman’s breastfeeding decision and duration (p = 0.05). Respondents working in maternal/child/family health were 14.3 times more likely to feel confident in their ability to provide lactation counseling, guidance, and recommendations (p = 0.03). Educational institutions and employers should provide all RDs and RNs with opportunities for personal reflection and lactation training while strengthening breastfeeding social norms.

Association of Racial Residential Segregation and Other Social Determinants of Health with HIV Late Presentation.

Understanding social determinants of HIV late presentation with advanced disease (LPWA) beyond individual-level factors could help decrease LPWA and improve population-level HIV outcomes. This study aimed to examine county-level social determinants of health (SDOH) with HIV late presentation. We aggregated datasets for analysis by linking statewide HIV diagnosis data from the South Carolina (SC) Enhanced HIV/AIDS Reporting System and multiple social contextual datasets (e.g., the American Community Survey). All adult (18 years and older) people with HIV diagnosed from 2014 to 2019 in SC were included. Linear mixed models with forward selection were employed to explore the association of county-level SDOH with the county-level three-year moving average percentage of LPWA and average delay time from HIV infection to diagnosis. Around 30% of new HIV diagnoses were LPWA in SC, and the mean delay time for people with LPWA was approximately 13 years. Counties with more racial residential segregation had longer average delay time (Adjusted beta = 5.079, 95% CI: 0.268 ~ 9.889). Regarding other SDOH, the increased percentage of LPWA was associated with fewer Ryan White centers per 100,000 population (Adjusted beta = -0.006, 95% CI: -0.011~-0.001) and higher percentages of the population with less than a high school education (Adjusted beta = 0.008, 95% CI: 0 ~ 0.015). Reducing county-level disparities in LPWA requires multifaceted interventions addressing multiple dimensions of SDOH. Targeted interventions are needed for counties with more Black residential segregation, fewer Ryan White centers, and higher percentages of less than high school education.

One health and social research in disease ecology: A social contextual study of vector-borne diseases in the Yucatan Peninsula, Mexico

Although disease ecology recognizes the multiplicity of factors involved in the (re)emergence of vector-borne diseases (VBD), it is necessary to strengthen attention to the social context and the social determinants of health. It is essential to integrate a sociocultural approach to health into the biological analysis of VBD ecology. To implement a coherent One Health approach in the prevention and control of VBD, it is pivotal to first understand the social and ecological interactions of the local context. Between October 2021 and June 2022, a social contextual study was made through surveys, semi-structured interviews and participatory activities in 12 localities with diverse ecological, economic and socio-cultural contexts in the Yucatan Peninsula. Through the perceptions of the populations on health and VBD, specifically mosquitoes, we gained knowledge on socio-cultural dynamics that influence people's relationship with pathogens. Local knowledge, management, and control of vectors; interactions with domestic and wild animals; and health-landscape relationship, were identified as factors that determine health-disease processes. This study contributed to a better understanding of local contexts and therefore, to the design of socially pertinent strategies for the reduction of vector-borne diseases risk scenarios in the study sites with an integrated approach.

HPV Status and Oral Health Symptom Patterning During Treatment and Survivorship in Patients With Head and Neck Cancer: A Longitudinal Analysis.

To describe longitudinal oral health symptom patterns of patients receiving concurrent chemotherapy and radiation therapy for head and neck cancer (HNC) and examine associations between phenotypic characteristics, including human papillomavirus (HPV) status and oral health symptoms. A pilot retrospective longitudinal chart review (N = 270) of patients with HNC at a northeastern U.S. regional cancer institute. HPV status and oral health symptoms (pain, mucositis, taste alteration, xerostomia, dysphagia, and candidiasis) were examined during treatment (six weeks) and survivorship (three months). Latent transition analysis was conducted across each time point. The latent transition analysis revealed classes with moderate to high symptom expression persisted into survivorship. The HPV-negative phenotype had higher symptom expression across treatment and survivorship. Patients with HPV-negative HNC may require early intervention, while considering social determinants of health to attenuate symptom expression and improve outcomes.

Spatial Cluster Analysis of the Social Determinants of Health and Fatal Crashes Involving US Geriatric and Non-Geriatric Road Users

Spatial Cluster Analysis of the Social Determinants of Health and Fatal Crashes Involving US Geriatric and Non-Geriatric Road Users

The Use of the CDC Preventive Health and Health Services Block Grant to Address Social Determinants of Health to Advance Health Equity.

State public health departments use federal funding to examine and address social determinants of health (SDOH) within their communities to improve health and advance health equity. Yet, most federal funding is categorical (ie, funding used for a specific program or narrow purpose), which can create barriers to addressing social and structural drivers of inequity. The Preventive Health and Health Services Block Grant (PHHS Block Grant) is a flexible funding mechanism that provides health departments the latitude to identify and fund initiatives that address local public health needs. It is unclear, however, to what extent health departments use this flexible resource to incorporate SDOH into their programs. Cross-sectional, descriptive analysis of state health department PHHS Block Grant program administrative data. This study examined PHHS Block Grant budgets and workplans for the federal Fiscal Year 2021 to assess whether state health departments aligned their grant-funded program with the national objectives associated with the Healthy People 2030 SDOH Framework. Forty-seven states and the District of Columbia were included in this study. Percent of states that used PHHS Block Grant funds to address SDOH; proportion of funding allocated to address SDOH; percentage of programs that addressed SDOH. Three-fourths (75%) of states allocated funds to 97 programs aligning with at least 1 Healthy People 2030 SDOH-related objective. Fifty of the programs were fully or primarily funded by the PHHS Block Grant. Results also show that as the states' PHHS Block Grant funding level increased so did the percent of states that allocated funding toward SDOH programs. This study shows that state health departments are using the PHHS Block Grant to address SDOH, and that the grant plays an important funding role for these programs. States are incorporating the grant into their funding strategies to address SDOH.

Social Determinants of Preterm Birth amongst Non-Hispanic Black Individuals.

Non-Hispanic Black individuals are disproportionately affected by preterm birth (PTB), a major driver of the racial disparity in infant mortality in the United States. The objective of this study is to identify indicators of social determinants of health (SDoH) that contribute to preterm birth amongst non-Hispanic Black individuals. Population-based retrospective case-control study of U.S. birth records (2012-2016). Factors potentially associated with PTB and considered indicators of SDoH were compared between singleton live births of non-Hispanic Black individuals delivering preterm (<37 weeks of gestation) and term (≥37 weeks of gestation). Logistic regression quantified the association between SDoH and PTB such as insurance, education, and prenatal care visits and reported as odds ratios (ORs; 95% confidence interval, CI). Of 2,763,235 live births to Black individuals, 340,480 (12%) occurred <37 weeks of gestation. Factors most strongly associated with PTB (p < 0.001), presented as OR (95% CI), included no prenatal care 3.0 (95% CI: 2.9-3.1) or insufficient prenatal care 2.7 (95% CI: 2.7-2.8), smoking during pregnancy 1.4 (95% CI: 1.43-1.47), unmarried 1.18 (95% CI: 1.17-1.19), lack of high school diploma 1.1 (95% CI: 1.12-1.40), lack of father of baby listed on birth certificate 1.22 (1.21-1.23), and Black paternal race 1.10 (1.08-1.12). Receipt of WIC (women, infants, and children) during the pregnancy had a protective effect on PTB risk in Black individuals, OR 0.83 (0.83-0.84). Pregnancies in Black individuals who are ≥35 years old, smoke tobacco, utilize Medicaid insurance, have less than a high school education, are unmarried, have little to no prenatal care, Black paternal race, and lack of father of baby listed on birth record had increased risk of PTB. Understanding the lived experience of Black pregnant people and these selected indicators of SDoH that contribute to the risk of PTB may inform development of interventions to address the racial disparity in PTB in the United States. · Preterm birth disproportionately affects Black individuals.. · SDoH are contributors to preterm birth.. · This study investigates social determinant influences on preterm birth among Black individuals..

The impact of social determinants of health on international migrants’ health outcomes: a bibliometric analysis

Purpose The aim of this study is to conduct an in-depth exploration of the research landscape concerning the impact of social determinants of health (SDH) on the health outcomes of international migrants. Design/methodology/approach Leveraging the extensive Scopus database, this study retrieved a total of 2,255 articles spanning the years 1993–2023. The framework for analysis used the SDH categories outlined by the World Health Organization. Findings The research landscape exhibited an apparent increase in the number of publications, but not a net increase in the research productivity. The USA emerged as the leading contributor to research output, with the Journal of Immigrant and Minority Health emerging as the most prolific publication venue, and the University of Toronto ranking as the most prolific institution. The SDH category that received the highest number of publications was the “community and social context”. Migrants from different regions in Asia (East, Central and South Asia) and those from Latin America and the Caribbean region appeared to be the most commonly researched. Highly cited articles predominantly delved into mental health outcomes arising from discrimination and migration policies. Research limitations/implications The findings proffer valuable insights for shaping future research endeavors, accentuating the imperative for diversified studies encompassing underrepresented domains, broader health outcomes and the inclusion of migrant populations from different world regions in investigative pursuits. Originality/value This study delivers a comprehensive analysis of the research landscape, unveiling critical trends in the realm of SDH and migrant health outcomes.

Cardiovascular health metrics and all-cause mortality in osteoarthritis, inflammatory arthritis, and unclassified arthritis patients: a national prospective cohort study

BackgroundArthritis notably elevates mortality risk. It remains unclear whether the cardiovascular health (CVH) metrics improves the risk of all-cause mortality in patients with all types of arthritis.MethodsThis study data from the National Health and Nutrition Examination Survey to probe the link between CVH and all-cause mortality among arthritis sufferers in the United States. CVH evaluation employed the Life's Essential 8 metrics. Mortality outcomes were scrutinized using Cox proportional hazard regression models. Additionally, a restricted cubic spline analysis delineated the linear relationship between CVH and mortality. The study also delved into the singular impact of each CVH component on mortality.ResultsIn the cohort of 5919 patients with arthritis, improved CVH was linked to lower all-cause mortality. Specifically, each 10-point increment in CVH score was associated with a substantial decline in all-cause mortality risk [unadjusted hazard ratio (HR): 0.77, 95% Confidence Interval (95% CI): 0.71–0.83, P < 0.001]. Adjustments for age, sex, race, and social determinants of health further refined the HR to 0.72 (95% CI: 0.67–0.79, P < 0.001). Higher versus lower CVH scores at baseline markedly reduced mortality risk, with the most substantial decrease seen in those with ideal CVH metrics (HR: 0.39, 95% CI: 0.26–0.59, P < 0.001). Similar results were not observed in patients with inflammatory arthritis, but were seen in those with osteoarthritis or degenerative arthritis, and unknown types of arthritis.ConclusionIdeal CVH substantially decreases all-cause mortality risk among patients with arthritis, confirming the critical role of CVH in arthritis management. This study advocates for CVH interventions as part of comprehensive arthritis treatment plans.

Mental Health Care and Policy (In)justice in Ontario: Making Intersections Visible

This paper applies an Intersectionality Based Policy Analysis Framework to Ontario’s current mental health plan – The Roadmap: A Plan to Build Ontario’s Mental Health and Addictions Services – in order to identify the contextual influences, underlying values and assumptions, which promote or undermine the uptake of human rights and equity as a mental health policy priority in Ontario. We found that dominant framings of the “problem” of mental health (as lack of access, coordination or integration, as a fiscal drain, as an economic burden, and as a clinical or medical problem) served to obscure and ignore the underlying social and structural conditions that impact mental health and the human rights violations that routinely occur in the context of “care.” We discuss the implications of The Roadmap ignoring social and structural determinants of health, and by way of contrast, explore how citizen engagement and activism can support rethinking mental health policy so that it is more just and equitable.

Role of Social Determinants of Health in Reproductive Cancer Care Among Women: A cross-sectional survey from diverse demographic and regional settings in India

Role of Social Determinants of Health in Reproductive Cancer Care Among Women: A cross-sectional survey from diverse demographic and regional settings in India

VAXXED &amp; BOOSTED: Increasing COVID-19 Vaccination Rates in West Greenville, NC, USA

Pitt County is ranked 48th out of the 100 counties in North Carolina for COVID-19 vaccination rates, with only 53.8% of the population fully vaccinated. West Greenville, located in Pitt County, is historically of lower economic status, leading to poorer social determinants of health. The goal of the VAXXED &amp; BOOSTED campaign was to increase COVID-19 vaccination rates in West Greenville by combating vaccine hesitancy and easing barriers to vaccination. From June through August of 2022, community ambassadors spoke to members of the community about their vaccine hesitancies and provided them with verified resources about the vaccine. Five vaccination events were hosted at the Community Crossroads Center and the JOY Soup Kitchen throughout July 2022. At each vaccination event, a survey was implemented to determine the effectiveness of the program. Through VAXXED &amp; BOOSTED, 52 people received COVID-19 vaccines: 13 for the first dose, 4 for the second, and 35 for boosters. Of 29 surveyed, 82.8% found community ambassadors helpful, and 51.7% interacted with them before the event. The event influenced 75.9% to get vaccinated, 82.8% learned something new, and 93.1% plan to encourage others to get vaccinated. Word of mouth likely played a significant role in event promotion, as only 51.7% interacted with ambassadors beforehand. The use of community ambassadors and educational events was successful in influencing people to get vaccinated against COVID-19 in West Greenville.

Social Determinants of Health Affect Psychological Distress among People with Disabilities

People with disabilities experience inequitable exposure to social determinants of health (SDOH) that contribute to disparate health outcomes, including psychological distress. There is little research examining which SDOH have the strongest effect on psychological distress among people with disabilities. This leaves healthcare providers and policy makers with insufficient information to make well-informed treatment decisions or allocate resources effectively. We explored the association between SDOH and disability and which factors may moderate the association between disability and psychological distress. Using data from the US Census Bureau’s Household Pulse Survey (Phase 3.5), we examined SDOH among people with and without disability (n = 26,354). Among people with disability, the odds of severe psychological distress were highest among those who had low incomes (OR = 4.41, 95% CI: 3.51–5.60), were food insecure (OR = 3.75, 95% CI: 3.43–4.10), housing insecure (OR = 3.17, 95% CI: 2.82–3.58), or were unable to work (OR = 1.98, 95% CI: 1.80–2.18). Only difficulty paying for household expenses moderated the association between disability and severe psychological distress (OR = 9.81, 95% CI: 7.11–13.64). These findings suggest that supporting employment and economic opportunities and improving access to safe and affordable housing and food may improve psychological well-being among people with disabilities.

"It's Really About Those Social Determinants of Health that Drive It": Addressing Food Insecurity in Rural Veterans.

The Department of Veterans Affairs (VA) employs numerous strategies to address food insecurity among rural veterans. This manuscript discusses findings from a quality improvement project examining factors impacting food insecurity among rural veterans. Qualitative interviews were conducted with VA expert informants (n = 30) who worked in national program offices addressing veteran food insecurity, site visit participants (n = 57) at three VA Medical Centers (VAMCs), and rural veterans who screened positive for food insecurity at the VAMC sites (n = 10). Interviews were analyzed with analysis matrices. Current VA programming includes a national food insecurity screening initiative and connecting veterans with local community resources. Veteran participants provided suggestions for addressing veteran food insecurity, including outreach and education. In addition, these interviews demonstrate that rural veteran food insecurity is intrinsically interwoven with other social determinants of health. Addressing rural veteran food insecurity must include strategies for understanding and supporting interconnected veteran needs.

Implementation of a Technology-Enabled Diabetes Self-Management Peer Coaching Intervention for Patients With Poorly Controlled Diabetes: Quasi-Experimental Case Study.

Patients with diabetes experience worse health outcomes and greater health care expenditure. Improving diabetes outcomes requires involved self-management. Peer coaching programs can help patients engage in self-management while addressing individual and structural barriers. These peer coaching programs can be scaled with digital platforms to efficiently connect patients with peer supporters who can help with diabetes self-management. This study aimed to evaluate the implementation of a technology-enabled peer coaching intervention to support diabetes self-management among patients with uncontrolled diabetes. MetroPlusHealth, a predominant Medicaid health maintenance organization based in New York City, partnered with Pyx Health to enroll 300 Medicaid patients with uncontrolled diabetes into its 6-month peer coaching intervention. Pyx Health peer coaches conduct at least 2 evidence-based and goal-oriented coaching sessions per month with their assigned patients. These sessions are focused on addressing both behavioral and social determinants of health (SDoH) with the goal of helping patients increase their diabetes self-management literacy, implement self-management behaviors, and reduce barriers to ongoing self-care. Data analyzed in this study included patient demographic data, clinical data (patient's hemoglobin A1c [HbA1c]), and program implementation data including types of behavioral determinants of health and SDoH reported by patients and types of interventions used by peer coaches. A total of 330 patients enrolled in the peer mentoring program and 2118 patients were considered to be on a waitlist group and used as a comparator. Patients who enrolled in the peer coaching program were older; more likely to be English speakers, female, and African American; and less likely to be White or Asian American or Pacific Islander than those in the waitlist condition, and had similar HbA1c laboratory results at baseline (intervention group 10.59 vs waitlist condition 10.62) Patients in the enrolled group had on average a -1.37 point reduction in the HbA1c score (n=70; pre: 10.99, post 9.62; P<.001), whereas patients in the waitlist group had a -0.16 reduction in the HbA1c score (n=207; pre 9.75, post 9.49; P<.001). Among a subsample of participants enrolled in the program with at least 2 HbA1c scores, we found that endorsement of emotional health issues (β=1.344; P=.04) and medication issues (β=1.36; P=.04) were significantly related to increases in HbA1c. This analysis of a technology-enabled 1-on-1 peer coaching program showed improved HbA1c levels for program participants relative to nonprogram participants. Results suggested participants with emotional stressors and medication management issues had worse outcomes and many preferred to connect through phone calls versus an app. These findings support the effectiveness of digital programs with multimodal approaches that include human support for improving diabetes self-management in a typically marginalized population with significant SDoH barriers.

Identifying and Characterizing Models of Substance Use Treatment in Outpatient Substance Use Treatment Facilities.

Given that individuals with substance use disorders (SUDs) have a variety of needs beyond substance use, it is critical to examine the comprehensiveness of services offered within outpatient SUD treatment facilities, where many individuals with SUDs receive care. This study's objective is to develop clusters of services offered, and assess organizational, policy, and environmental characteristics associated with having a more comprehensive treatment model. We conducted a principal component analysis (PCA) using data on SUD treatment facilities (n=8, 197) from the 2022 Mental Health and Addiction Treatment Tracking Repository, a national database of SUD treatment facilities. We applied a K-means cluster analysis on the generated components to cluster facilities by service offerings, and calculated the mean for different organizational, policy and environmental characteristics for each cluster. We retained five components from the PCA which represented the availability of different services (Pharmacotherapies, Infectious Disease and Harm Reduction, Supportive and Social Determinant of Health (SDOH) Services, Psychosocial Services, and General Healthcare.) The cluster analysis resulted in five SUD service models, with the most comprehensive having the highest percentage of accredited and Medicaid-accepting facilities, and facilities that were government-operated and located in a Medicaid expansion state, and the least comprehensive having lowest percentage of accredited, licensed and Medicaid-accepting facilities, and the highest percentage of private for-profit facilities. Our study found that SUD treatment facilities varied in the availability of five treatment components, but more comprehensive service models had a higher percentage of facilities that were licensed, accredited, and accepting Medicaid.

CIC 2023: Enhancing Referrals to the Supplemental Nutrition Assistance Program (SNAP) through Clinical Integration of a Standards-Based Decision Support System.

The Supplemental Nutrition Assistance Program (SNAP) is one of the most successful national programs to reduce poverty and improve health outcomes, but millions of Americans who qualify still do not have access to SNAP, and limited data is available to determine how referrals to the program can be completed successfully. We aimed to design and develop a standards-based digital care coordination platform to support closed-loop social services referrals between patients and social and health care providers; and demonstrate the feasibility to screen, diagnose, plan, and complete interventions with selected patients in real-settings. We partnered with community members to design the platform through Community Engagement Studios and with a Federally Qualified Health Center, Local Mental Health Authority, and Food Bank to determine the features and workflow requirements of the platform design. We customized currently available systems to use Fast Healthcare Interoperability Resources (FHIR) Application Programming Interfaces (APIs) that could exchange information in real-time across providers and participants. The platform was successfully demonstrated through a pilot where patients were recruited in clinical settings and referred to a Food Bank that provided SNAP application assistance to study participants. We translated the requirements of the platform to national standards and required workflows of providers and patients. Study participants were notified electronically of the specific steps to follow to complete their SNAP applications while receiving support from specialists from the Food Bank. The pilot demonstrated the feasibility of collecting granular social service referral information that can be used to better address gaps in social care. The pilot also highlighted the importance of further coordination on the usage and harmonization of needs assessment nationally and that current digital systems are still not ready to fully utilize national Social Determinants of Health (SDOH) data standards.