Implementation of a social determinants of health screening and referral process in a primary care setting: a quality improvement project

Abstract

A goal of Healthy People 2030 is to address SDOH and improve worldwide health outcomes (Healthy People 2030, 2024b). One primary care clinic in rural Montana, significantly lacks an efficient process for SDOH screening, intervention, and referral for their patient population. A gap exists with SDOH screening process, which leads to patients with unmet SDOH needs potentially falling through the cracks. Therefore, this leads to patients having difficulty managing their care needs, potentially resulting in worsening health outcomes. To facilitate the screening process and address the needs that are identified, the literature recommends: (a) EHR utilization, (b) provider and support staff education, (c) role identification, (d) community resources/services identification, (e) and development of universal screening processes (Brown et al., 2021; Jordanova et al., 2024; Kostelanetz et al., 2022; Rudisill et al., 2023). To address the needs of the clinic as evidenced by the literature, a QI project will be implemented to develop an efficient SDOH screening and referral process.