Importance Evidence-based guidance is limited on how clinicians should screen for social risk factors and which interventions related to these risk factors improve health outcomes. Objective To describe research on screening and interventions for social risk factors to inform US Preventive Services Task Force considerations of the implications for its portfolio of recommendations. Data Sources Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Sociological Abstracts, and Social Services Abstracts (through 2018); Social Interventions Research and Evaluation Network evidence library (January 2019 through May 2021); surveillance through May 21, 2021; interviews with 17 key informants. Study Selection Individual-level and health care system–level interventions with a link to the health care system that addressed at least 1 of 7 social risk domains: housing instability, food insecurity, transportation difficulties, utility needs, interpersonal safety, education, and financial strain. Data Extraction and Synthesis One investigator abstracted data from studies and a second investigator evaluated data abstractions for completeness and accuracy; key informant interviews were recorded, transcribed, summarized, and integrated with evidence from the literature; narrative synthesis with supporting tables and figures. Main Outcomes and Measures Validity of multidomain social risk screening tools; all outcomes reported for social risk–related interventions; challenges or unintended consequences of screening and interventions. Results Many multidomain social risk screening tools have been developed, but they vary widely in their assessment of social risk and few have been validated. This technical brief identified 106 social risk intervention studies (N = 5 978 596). Of the interventions studied, 73 (69%; n = 127 598) addressed multiple social risk domains. The most frequently addressed domains were food insecurity (67/106 studies [63%], n = 141 797), financial strain (52/106 studies [49%], n = 111 962), and housing instability (63/106 studies [59%], n = 5 881 222). Food insecurity, housing instability, and transportation difficulties were identified by key informants as the most important social risk factors to identify in health care. Thirty-eight studies (36%, n = 5 850 669) used an observational design with no comparator, and 19 studies (18%, n = 15 205) were randomized clinical trials. Health care utilization measures were the most commonly reported outcomes in the 68 studies with a comparator (38 studies [56%], n = 111 102). The literature and key informants described many perceived or potential challenges to implementation of social risk screening and interventions in health care. Conclusions and Relevance Many interventions to address food insecurity, financial strain, and housing instability have been studied, but more randomized clinical trials that report health outcomes from social risk screening and intervention are needed to guide widespread implementation in health care.

/pdf/screening-and-interventions-for-social-risk-factors-4zvyo7pucs.pdf

Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force

The health and wellbeing consequences of social determinants of health and health behaviours are well established. This has led to a growing interest in social prescribing, which involves linking people to services and supports in the community and voluntary sectors to address non-medical needs. However, there is considerable variability in approaches to social prescribing with little guidance on how social prescribing could be developed to reflect local health systems and needs. The purpose of this scoping review was to describe the types of social prescribing models used to address non-medical needs to inform co-design and decision-making for social prescribing program developers.We searched Ovid MEDLINE(R), CINAHL, Web of Science, Scopus, National Institute for Health Research Clinical Research Network, Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registry Platform, and ProQuest - Dissertations and Theses for articles and grey literature describing social prescribing programs. Reference lists of literature reviews were also searched. The searches were conducted on 2 August 2021 and yielded 5383 results following removal of duplicates.148 documents describing 159 social prescribing programs were included in the review. We describe the contexts in which the programs were delivered, the program target groups and services/supports to which participants were referred, the staff involved in the programs, program funding, and the use of digital systems.There is significant variability in social prescribing approaches internationally. Social prescribing programs can be summarised as including six planning stages and six program processes. We provide guidance for decision-makers regarding what to consider when designing social prescribing programs. 

/pdf/models-of-social-prescribing-to-address-non-medical-needs-in-3md6ney0.pdf

Models of social prescribing to address non-medical needs in adults: a scoping review

ObjectivesWhile healthcare organizations increasingly aim to address the social determinants of health (SDOH) in the clinic setting, there is little guidance on which staff are best equipped to ass...

https://journals.sagepub.com/doi/pdf/10.1177/21501327211021021

Workforce Models to Screen for and Address Patients' Unmet Social Needs in the Clinic Setting: A Scoping Review.

US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.

Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health.

BACKGROUND It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it. PURPOSE OF STUDY This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation. METHODS Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes. RESULTS Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs. CONCLUSION Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

/pdf/primary-care-based-interventions-to-address-the-financial-3915d597p3.pdf

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature.

Purpose: Social and economic factors have been shown to affect health outcomes. In particular, social determinants of health (SDH) are linked to poor health outcomes in children. Research and some professional academies support routine social needs screening during primary care visits. Translating this recommendation into practice remains challenging due to the resources required and dearth of evidence-based research to guide health center level implementation. We describe our experience implementing a novel social needs screening program at an academic pediatric clinic. Methods: The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using community health workers (CHWs) as part of routine primary care visits. Our multidisciplinary team performed process mapping, developed workflows, and led ongoing performance improvement activities. We established key elements of the CLC program through an iterative process We conducted social needs screens at 65% of eligible well-child visits from May 2017 to April 2018; 19.7% of screens had one or more positive responses. Childcare (48.8%), housing quality and/or availability (39.9%), and food insecurity (22.8%) were the most frequently reported needs. On average, 76% of providers had their patients screened on more than half of eligible well-child visits. Discussion: Our experience suggests that screening for social needs at well-child visits is feasible as part of routine primary care. We attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.

https://journals.sagepub.com/doi/pdf/10.1177/2150132719899207

From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center.

Social and environmental factors have an outsized effect on one's health. Children are particularly impacted by the adverse effects of poverty. While social determinants of health (SDH) screening in healthcare settings has proliferated there remain gaps in best practices for screening processes. As research has shown that patient navigation leads to an improvement in unmet social needs and family-reported child health, warm handoffs may be a key factor in assuring that the social needs of families are effectively addressed. Using quality improvement (QI) methods our pediatric clinic worked to increase the warm handoff rate between Community Health Workers (CHWs) and patients with unmet social needs. CHW warm handoff rates increased two-fold over the intervention period. Our results illustrate that QI methods can be used to optimize workflows to increase warm handoffs with CHWs. This is important as health centers work to improve their social needs screening and referral programs.

https://journals.sagepub.com/doi/pdf/10.1177/21501327211023883

“Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology”

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From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center.

“Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology”