Screening and documentation of social determinants of health in primary care

Thumbnail Image



Journal Title

Journal ISSN

Volume Title


Montana State University - Bozeman, College of Nursing


Social determinants of health (SDOH) are the conditions of the environments in which people live, work, learn, and play that influence their overall health outcomes. The project's purpose was to increase SDOH screening and documentation in a small, family nurse practitioner-led, primary care practice where social needs were not routinely screened for or addressed during patient encounters. The patients participating in the quality-improvement project completed the 11-item Accountable Health Communities Health-Related Social Needs screening tool developed by the Centers for Medicare and Medicaid. The screening tool was provided to all new patients and patients scheduled for routine annual wellness care during a 7-week period. The completed screening tools were provided to the family nurse practitioner (FNP) to review and subsequently assign an International Classification of Disease (ICD) diagnosis code in the patient's electronic health record (EHR), if unmet SDOH needs were identified. The project also collected data on the number of eligible patients screened and the number of screening tools scanned into screened patient's EHRs. The results of the quality-improvement project include that 90% of eligible patients were screened for unmet SDOH needs, with 84% of those screening tools uploaded into the EHR. Lastly, the ICD diagnosis codes entered by the FNP were tabulated using a frequency table, and insufficient housing was the most frequently identified unmet SDOH need in the patient population screened. Insufficient housing accounted for 33% (4 of 11) of the total number of unmet SDOH needs identified. The quality-improvement project highlighted the importance of screening and documenting SDOH as they provide deeper insight into the complex role unmet SDOH plays in the overall health of patients. The project also shed light on future avenues the FNP can pursue to cater to needs identified in their patient population with the screening tool, including referrals to community resources such as affordable housing options or housing voucher programs.




Copyright (c) 2002-2022, LYRASIS. All rights reserved.