Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Elizabeth Tovar

Clinical Mentor

Dr. Beverly Woods

Committee Member

Dr. Julianne Ossege



Background. Despite ample strong evidence linking social determinants of health (SDOH) and unmet social needs to higher healthcare costs and worse health outcomes across the lifespan, only 16% of healthcare practices screen their patients for social needs. Various barriers contribute to low screening rates, including uncertainty about best methods for screening, the amount of time it takes to screen, and lack of confidence in knowing what to do once needs have been identified. As movements toward value-based models of care change the healthcare landscape, healthcare systems must find practical and effective methods to effectively screen for social needs utilizing a multi-level approach.

Purpose. The purpose of this study was to foster organizational readiness for the implementation of social needs screening through the evaluation of patient and staff perceptions regarding social needs screening practices.

Methods. This quality improvement (QI) project took place in a primary care clinic serving a diverse population. Staff (N=11) and patients (N= 40) who met inclusion criteria completed a survey related to social needs screening perceptions and practices (staff only) and screening preferences (staff and patients) over a one-week time period. Two weeks following survey completion, tailored education, survey results, and screening recommendations were provided for available staff (N=4) through a 20-minute in-person educational presentation. A post-survey evaluated the impact of the presentation components and initial perceptions regarding application of recommendations into clinical practice.

Results. Thirty five percent (n=14) of the patient population preferred face-to-face screening methods, while 27.5% (n=11) prefer the paper method. Conversely, 36.4% percent (n=4) of staff prefer electronic screening via a tablet device or similar in the waiting area. The biggest barrier to staff for screening for social needs was lack of time followed by a lack of resources to address identified needs. The educational session was reportedly helpful and informative for participating staff (N=4) and they all planned to apply something they learned into their clinical practice. Staff members were asked two months later if they had implemented the recommended resources, documentation, or screening into clinical practice. One respondent had not yet utilized the components, but expressed using it should the need arise. The other respondent described the positive impact, having already shared the community resource finder, the AAFP EveryONE Project “Neighborhood Navigator,” with other providers. The respondent noted the teamwork the project fostered, sparking the rooming staff and interpreters to begin facilitating the screening process with the provider and social worker.

Conclusion. Perspectives on the best methodology for social needs screening differed between the staff and patient population. Evidence strongly supports the use of a technological screening method to maximize screening consistency, efficiency, and effectiveness. When support is available to assist patients if technological difficulties occur, they are typically more receptive to using technology-based methods for healthcare related activities. Recommendations from this study include the use of the electronic health record (EHR) based screening method as well as staff education prior to implementation. An educational session prior to implementation of social needs screening with inclusion of valid screening tools, documentation information, and community resources found through the AAFP EveryONE Project “Neighborhood Navigator” was helpful in preparing the organization for piloting social needs screening in a specific setting. This feasible and effective approach can foster long-term success in assessing and addressing social needs in clinical practice.