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Date Available
5-4-2026
Year of Publication
2026
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice
College
Nursing
Department/School/Program
Nursing
Faculty
Dr. Julianne Ossege
Committee Member
Katie Jo Aaron
Faculty
Dr. Elizabeth Tovar
Faculty
Dr. Julianne Ewen
Abstract
Background: Social determinants of health (SDoH) significantly affect health outcomes and healthcare utilization, particularly in rural communities. In 2024, the Centers for Medicare & Medicaid Services mandated SDoH screenings in the inpatient setting, with recommendation to implement in rural clinics without specifying a standardized tool, resulting in inconsistent identification of needs, e.g., food insecurity, housing instability, mental health concerns, financial strain, and transportation barriers.
Purpose: This quality improvement initiative implemented a standardized SDoH screening tool in a rural outpatient clinic to evaluate changes in referral rates to community-based resources pre- and post-implementation and to improve patient reporting of social needs.
Sample: English-fluent adults aged ≥18 years presenting for chronic care visits.
Methods: A non-experimental QI design was used. The clinic adopted the parent hospital’s SDoH screening tool for outpatient use. Patients completed the screening at check-in, and providers used responses to guide referral discussions. Pre- and post-implementation chart reviews compared referral rates.
Results: Thirty participants were included (mean age 54.1 ± 16.5 years; 50% female). Prior SDoH referral occurred in 3.3%; post-implementation referral increased to 13.3%. A total of nine social needs were identified among the four participants who requested community referrals. The most frequently reported needs included transportation assistance (n = 3) and food assistance (n = 3), followed by mental health support (n = 2) and employment assistance (n = 1). Participants receiving referrals had higher screening scores (p=0.017). Referral status was not associated with gender (p=0.598) or age (p=0.148), and no significant pre–post referral change was observed (p=0.375).
Conclusion: Although statistical significance was not achieved, the implementation of standardized SDoH screening enhanced the identification of unmet social needs and facilitated linkage to community resources in a rural primary care setting. Additionally, higher screening scores were associated with increased likelihood of referral, suggesting the tool’s effectiveness in identifying patients with greater social risks.
Recommended Citation
Combs, Laura C., "Advancing Rural Health Equity Through Systematic SDoH Screening- A Quality Improvement Initiative" (2026). DNP Projects. 519.
https://uknowledge.uky.edu/dnp_etds/519
Included in
Family Practice Nursing Commons, Public Health and Community Nursing Commons, Rural Health Commons
