Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico.
Open accessAbstract
Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients' social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients.
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Some studies have shown promise in both the logistical feasibility and clinical utility of standardized data instruments for social determinants of health.
“Some studies have already shown promise in both the logistical feasibility and clinical utility of these instruments [77].”
From Bias in medical AI: Implications for clinical decision-making (2024) · cites this paper as [77]
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Wang, G. X., Gauthier, R., Gunter, K. E., Johnson, L., Zhu, M., Wan, W., Tanumihardjo, J. P., & Chin, M. H. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07918-2 · Cited by 10 · see citing works
Social Determinants of Health Screening and Referral: Innovation in Graduate Nursing Education
Buys, K. C., & Somerall, D. (2018) · Journal of Nursing Education · doi:10.3928/01484834-20180815-13 · Cited by 10 · see citing works
Brown, E. A., Kinder, H., Stang, G. S., & Shumpert, W. (2023) · Humanities and Social Sciences Communications · doi:10.1057/s41599-023-01599-w · Cited by 9 · see citing works
Association Between Unmet Essential Social Needs and Influenza Vaccination in US Adults
Parente, D. J., Murray, M. J., & Woodward, J. M. (2021) · Journal of General Internal Medicine · doi:10.1007/s11606-021-06902-6 · Cited by 8 · see citing works
Assessing Retention in a Free Diabetes Clinic
Buys, K. C., Selleck, C. S., & Buys, D. R. (2019) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2018.12.003 · Cited by 8 · see citing works
Frier, A., Devine, S., Barnett, F., McBain‐Rigg, K. E., & Dunning, T. L. (2022) · PLoS ONE · doi:10.1371/journal.pone.0271980 · Cited by 8 · see citing works
Hughes, L. S. (2016) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2016.03.160120 · Cited by 8 · see citing works
Performance of 4 Methods to Assess Health-Related Social Needs
Vest, J. R., Wu, W., Gregory, M. E., Kasthurirathne, S. N., Mendonça, E. A., Bian, J., Magoč, T., Grannis, S. J., McNamee, C., & Harle, C. A. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.27426 · Cited by 7 · see citing works
Wetta, R. E., Severin, R. D., & Gruhler, H. (2019) · Health Informatics Journal · doi:10.1177/1460458219882265 · Cited by 6 · see citing works
Screening for the social determinants of health: Referring patients to community-based services
Mullen, L. G., Oermann, M. H., Cockroft, M. C., Sharpe, L. M., & Davison, J. A. (2023) · Journal of the American Association of Nurse Practitioners · doi:10.1097/jxx.0000000000000922 · Cited by 7 · see citing works
Development of a comprehensive survey to assess key socioecological determinants of health
Smith, B., Smith, B. P., Hollis, R. H., Jones, B. A., Shao, C. C., Katta, M. H., Wood, L. N., Bateman, L. B., Oates, G. R., & Chu, D. I. (2023) · Surgery · doi:10.1016/j.surg.2023.11.011 · Cited by 7 · see citing works
Patients’ Willingness to Accept Social Needs Navigation After In-Person versus Remote Screening
Steeves-Reece, A. L., Davis, M. M., Larson, J. H., Major-McDowall, Z., King, A. E., Nicolaidis, C., Goldberg, B., Richardson, D. M., & Lindner, S. (2023) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2022.220259r1 · Cited by 7 · see citing works
Osilla, K. C., Meredith, L. S., Griffin, B. A., Martineau, M., Hindmarch, G., & Watkins, K. E. (2023) · Contemporary Clinical Trials · doi:10.1016/j.cct.2023.107294 · Cited by 6 · see citing works
Implementation of Social Needs Screening and Intervention in Primary Care
Chang, E., Guzman, I. A., Glowacki, N., & Khatib, R. (2025) · Annals of Internal Medicine · doi:10.7326/annals-25-00308 · Cited by 7 · see citing works
Brown, E. A., & Jones, R. (2024) · BMC Medical Education · doi:10.1186/s12909-024-05302-8 · Cited by 6 · see citing works
Carter, B. J., Jafry, M. Z., Siddiqi, A. D., Rogova, A., Liaw, W. R., & Reitzel, L. R. (2023) · Elsevier eBooks · doi:10.1016/b978-0-12-824010-6.00016-2 · Cited by 7 · see citing works
What Are Social Determinants of Health and Why Should They Matter to an Orthopaedic Surgeon?
Meacock, S. S., Khan, I. A., Hohmann, A. L., Cohen-Rosenblum, A. R., Krueger, C. A., Purtill, J. J., & Fillingham, Y. A. (2024) · Journal of Bone and Joint Surgery · doi:10.2106/jbjs.23.01114 · Cited by 6 · see citing works
Allen, N. A., Zagarins, S., & Welch, G. W. (2017) · Diabetes Spectrum · doi:10.2337/ds16-0031 · Cited by 6 · see citing works
- Authors
- Page-Reeves, J., Kaufman, W., Bleecker, M., Norris, J., McCalmont, K., Ianakieva, V., Ianakieva, D., & Kaufman, A.
- Affiliations
- University of New Mexico (US)
- ORCID
- Kaufman, A.
- Venue
- The Journal of the American Board of Family Medicine
- Published
- 2016-05-01
- Volume
- 29
- Issue
- 3
- Pages
- 414-418
- ISSN
- 1557-2625 (ISSN-L)
- 1558-7118
- OpenAlex
- W2384838247
- Cited by
- 172
- References
- 10
- Citations by year
- 2026: 13 · 2025: 17 · 2024: 20 · 2023: 26 · 2022: 18 · 2021: 16 · 2020: 19 · 2019: 17 · 2018: 12 · 2017: 8 · 2016: 6
- FWCI
- 18.91
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of the American Board of Family Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Health › Public Health and Social Inequalities
- Social Sciences › Health › Health disparities and outcomes
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Keywords
- social determinants of health, social needs screening, primary care, community health workers, medical assistants, Medicaid, managed care, feasibility, Albuquerque
- MeSH terms
- Community Health Workers, Family Practice, Feasibility Studies, Health Policy, Humans, Insurance, Health, Reimbursement, Medicaid, New Mexico, Pilot Projects, Primary Health Care, Surveys and Questionnaires, Referral and Consultation, Socioeconomic Factors, United States, Social Determinants of Health
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