Clinician Experiences with Screening for Social Needs in Primary Care
Open accessAbstract
We aimed to understand primary care clinicians' experiences of administering a social needs screening instrument.
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Cites
Statistics
Claims the paper makes
0 of 35 cited sources checked · 0 supported · 0 flagged
- Findingown data
The most common domains for positive screens were physical activity (53.0%), dental (25.2%), and alcohol use (14.6%).
“The most common domains for positive screens were physical activity (53.0%), dental (25.2%), and alcohol use (14.6%).”
Quote in the paperNot a substantial claim- Rests on an assumption: The social needs survey accurately identifies patients who have social needs.
- Findingown data
There was a wide range in how often patients wanted help when they screened positive, from 100% for safety to 3.0% for physical activity.
“There was a significant range in how often patients wanted help when they screened positive with 100% of patients screening positive for safety asking for help but only 3.0% of patients screening positive for physical activity asking for help.”
Quote in the paperNot a substantial claim- Rests on an assumption: Patients' self-reported desire for help accurately reflects their need for assistance.
- Findingown data
The study found substantial social needs in a subset of a population in an affluent community.
“Furthermore, whereas other studies have focused on social needs screening in underserved communities, our study was able to demonstrate substantial social needs in a subset of a population in an affluent community.”
Quote in the paperSubstantial claim- Rests on an assumption: The social needs survey accurately identifies patients who have social needs.
- Findingown data
Clinicians reported in postencounter diary entries that the social needs survey changed care in 22.5% of encounters.
“Clinicians reported in their postencounter diary entries that the social needs survey helped change care in 22.5% of encounters (Table 2).”
Quote in the paperSubstantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
- Findingown data
The least common domains for positive screens were social connections (1.6%), safety (2.4%), and education (2.4%).
“The least common domains for positive screens were social connections (1.6%), safety (2.4%), and education (2.4%).”
Quote in the paperNot a substantial claim- Rests on an assumption: The social needs survey accurately identifies patients who have social needs.
- Findingown data
86.2% of patients screened positive in at least one of the 16 social needs domains.
“We found that 86.2% of patients screened positive in at least 1 of the 16 domains.”
Quote in the paperNot a substantial claim- Rests on an assumption: The social needs survey accurately identifies patients who have social needs.
- Premisecitation
Adding more required data collection for primary care clinicians could be burdensome without benefit if clinicians cannot address social needs.
“Furthermore, adding more required data collection for primary care clinicians could be burdensome without any benefit32–34 if clinicians are not able to address social needs.35,36”
Quote in the paperSubstantial claim0 of 5 sources checked- cites [32]
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- cites [33]
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- cites [34]
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- cites [36]
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- Study design and conductnone given
The study had a limited sample size from clinics within one health system.
“Third, we had a limited sample size from clinics within one health system.”
Quote in the paperNot a substantial claim - Premisecitation
Most studies examining social determinants of health screening have been conducted in underserved settings.
“To date, most studies examining SDH screening have taken place in underserved settings.28–30”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [28]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [29]
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- cites [30]
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- Interpretationreasoning
It would likely be overwhelming for primary care clinicians to address social needs in more than half of their patients.
“It would likely be overwhelming for primary care clinicians to address social needs in more than half of their patients”
Quote in the paperNot a substantial claim - Premisecitation
Pilot studies have shown that primary care clinicians can feasibly screen for social determinants of health in various primary care settings using various mechanisms.
“These studies have demonstrated that it is feasible for primary care clinicians to screen for SDH in a variety of primary care settings by using a variety of mechanisms.28–31”
Quote in the paperSubstantial claim0 of 4 sources checked- cites [28]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [29]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [30]
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- cites [31]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Study design and conductown data
Of 215 eligible patients, 123 completed the social needs survey and reviewed the results with their clinician.
“A total of 215 eligible patients in the care of the 17 clinicians were identified. Of these, 123 patients completed the social needs survey and reviewed the results with their clinician.”
Quote in the paperNot a substantial claim - Interpretationown data
The study suggests that clinicians may find value in screening for and addressing social determinants of health in their practice.
“Our study suggests that clinicians may find value in screening for and addressing social determinants of health in their practice.”
Quote in the paperSubstantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
- Borderline: one of the tests for a substantial claim is unclear. 1
- Classified as probably not a substantial claim. 16
- May combine two claims. 20
Borderline on S4 (based): unclear from the text.
Findingnone givenClinicians reported that the social needs survey helped them know the patient better in 52.5% of encounters.
“Furthermore, clinicians reported that in 52.5% of encounters, the social needs survey helped them know the patient better (Table 2).”
Quote in the paperNot a substantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).
Findingnone givenOnly 3.3% of patients wanted help in any domain.
“However, only 3.3% of patients wanted help in any domains.”
Quote in the paperNot a substantial claim- Rests on an assumption: Patients' self-reported desire for help accurately reflects their need for assistance.
May combine two claims.
Findingown dataClinicians expressed concerns about being overwhelmed by too much information, administrative burden, and insufficient resources to address identified needs.
“Clinicians also identified concerns about being overwhelmed with too much information and administrative burden. Furthermore, they were concerned about the lack of resources to address any identified needs.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe practices jointly serve a patient population that is predominantly commercially insured (96.0%), generally more affluent, and primarily English-speaking (84.9%).
“The practices jointly serve a patient population that is predominantly commercially insured (96.0%), generally more affluent, and speak English as their preferred language (84.9%).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataWhen physical activity was excluded, 70.7% of patients screened positive in at least one domain and 3.3% wanted help in any domain.
“When we excluded physical activity, 70.7% of patients screened positive in at least 1 domain and 3.3% wanted help in any domain.”
Quote in the paperNot a substantial claim- Rests on an assumption: The social needs survey accurately identifies patients who have social needs.
- Rests on an assumption: Patients' self-reported desire for help accurately reflects their need for assistance.
May combine two claims.
Findingown dataClinicians reported better understanding of patients' finances, relationships with family and friends, beliefs and values, and behavioral health needs.
“Specifically, clinicians reported they were able to better understand their patients’ finances, relationships with family and friends, beliefs and values, and behavioral health needs.”
Quote in the paperSubstantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataConcerns remained that social needs screening might not significantly change practice and whether the health care system is the right place to address social needs.
“However, there remained concern that screening for social needs might not change practice significantly and whether or not the health care system is the right place to address social needs.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataReported ways the survey changed care included more exercise and dietary counseling, addressing financial barriers to medications, addressing behavioral health issues, and helping with transportation to clinical services.
“Ways that the social needs survey changed care included providing more exercise and dietary counseling, helping address financial barriers to medications and being mindful of medication costs when prescribing, addressing behavioral health issues, and helping with transportation to access clinical services.”
Quote in the paperSubstantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
Classified as probably not a substantial claim. May combine two claims.
Findingown dataClinicians in the study spoke about needing more meaningful resources, more education on addressing social needs, and collaborations with community partners.
“Clinicians in our study spoke about the need for more meaningful resources to address social needs, more education on how to best address social needs, and the need for collaborations with community partners to adequately address social needs.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAlthough some clinicians were skeptical before the surveys, they identified value in improved interactions and knowledge of patients after the surveys.
“Specifically, although some clinicians expressed skepticism about the value of collecting SDH information before administering the social needs surveys to patients, clinicians identified value in improving interactions with patients and knowledge of their patients after the surveys were administered.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataClinicians expressed interest in exploring broader application of social needs screening and in determining whether addressing social needs improves health outcomes.
“When completing the learning collaborative series, clinicians indicated interest in further exploring how social needs screening might be more broadly applied. They indicated interest in finding out whether or not addressing social needs might improve health outcomes”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationNAM issued a consensus statement recommending routine collection of 12 social determinants of health domains in electronic health records.
“To bolster the most recent momentum to address SDH in primary care, NAM released a consensus statement recommending that 12 SDH domains be routinely collected and made available in electronic health records.26,27”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [26]
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- cites [27]
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PremisecitationSocial determinants of health have a demonstrated effect on health outcomes.
“Social determinants of health (SDH) have a demonstrable influence on health outcomes.1–6”
Quote in the paperNot a substantial claim0 of 6 sources checked- cites [1]
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- cites [6]
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Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe National Academy of Medicine, the Centers for Medicare and Medicaid Services, and the World Health Organization have called for integrating primary care and public health to address social determinants of health.
“The National Academy of Medicine (NAM), the Centers for Medicare and Medicaid Services, and the World Health Organization have called for the integration of primary care and public health to address SDH.15–18”
Quote in the paperNot a substantial claim0 of 4 sources checked- cites [15]
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- cites [16]
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- cites [18]
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PremisecitationIn the United States, most resources are spent disproportionately on direct medical care rather than public health and social determinants.
“However, the majority of resources in the United States is disproportionately spent on direct medical care instead of public health and social determinants.14”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [14]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationResearch increasingly indicates that social determinants of health affect health outcomes more than medical care does.
“Growing research is showing that SDH plays a far greater role on health outcomes than medical care.8–13”
Quote in the paperNot a substantial claim0 of 6 sources checked- cites [8]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [9]
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- cites [10]
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- cites [11]
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- cites [13]
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May combine two claims.
Study design and conductreasoningSelection bias may exist in the patient sample because the cold-spotting method may have excluded patients with social needs who did not live in a cold spot, patients who could not read English were excluded, and patients who did not show up for visits were excluded.
“Second, selection bias may exist from our patient sample for 3 reasons: (1) the cold-spotting methodology used may have excluded patients who did not live in a cold spot who have social needs, (2) patients who could not read English were excluded, and (3) patients who did not show up for their visit were excluded.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationown dataFinding out about patients' social needs may change care and may help improve the patient-clinician relationship.
“Finding out about patients’ social needs may not only change care but also may help improve the patient-clinician relationship.”
Quote in the paperSubstantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe participating practices mainly serve patients in counties that collectively have among the highest average incomes in the United States.
“These counties collectively have among the highest average income within the United States.39”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [39]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
May combine two claims.
InterpretationcitationImprovements in addressing social needs and in the patient-clinician relationship may reduce disparities in cold spot neighborhoods.
“Improvement in both of these areas may in turn be able to reduce the disparities that are found in patients who come from these cold spot neighborhoods.37”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [37]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
May combine two claims.
PremisecitationA parallel study by the authors demonstrated methods for calculating cold spots within a community and used those definitions to select patients for the intervention in an affluent community.
“In a parallel study, we demonstrate several means of calculating cold spots within a community38 and then used these definitions to select patients for our intervention in an affluent community.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [38]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S2 (checkable).
Interpretationown dataThis finding may support screening a subset of patients for social needs in affluent communities.
“This may make the case for screening a subset of patients for social needs in affluent communities.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductreasoningThe study may not represent clinician experiences or the proportion of patients with social needs in other settings.
“Although our study demonstrated that there is value in screening for social needs even in an affluent population, it may not be representative of clinician experiences in other settings and may not represent the proportion of patients with social needs in other settings.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductreasoningThe patient sample is small and may limit findings from patient responses on the social needs survey.
“Fifth, because this study focused on the experiences of clinicians screening for social needs, our sample of patients is small and may limit findings from the patient responses on the social needs survey.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningClinician diary entries were collected online within one week after the clinical encounter to reduce recall bias.
“Collected on-line within a week after the clinical encounter with each patient to limit recall bias”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataSeventeen clinicians participated and all completed the study.
“Seventeen clinicians participated and 100% completed the study.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningScreening for social needs may help both address patients' social needs and build the patient-clinician relationship.
“Because primary care values patient relationships and continuity of care, screening for social needs may play a role not only in helping address the social needs of patients but also in building the patient-clinician relationship.”
Quote in the paperSubstantial claim- Rests on an assumption: Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
May combine two claims.
Study design and conductreasoningThe clinician sample may not represent all primary care clinicians and may be biased by self-selection of clinicians more interested in addressing social determinants of health.
“First, our clinician sample may not be representative of all primary care clinicians, but rather biased by self-selection to participate among clinicians more interested in addressing SDH.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe social needs survey was derived from NAM's social needs measures and the Hennepin County Lifestyle Survey but is not a validated instrument.
“Fourth, although our social needs survey (Appendix A) is derived from NAM’s social needs measures and the Hennepin County Lifestyle Survey, it is not a validated instrument.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataThree reviewers used a template approach to code qualitative data, with two reviewers independently coding each transcript and resolving discrepancies by consensus.
“Three reviewers (ST, WL, and AK) used a template approach, which involves the directed coding of collected qualitative material based on a code manual47, to capture facilitators, barriers, and suggestions to improve collection of social needs and address identified social needs.”
- Also stated in: § Qualitative Analysis · plain
“Two reviewers coded each transcript independently. Merged data were reviewed for discrepancies in coding and discussed by all 3 reviewers until reaching a consensus.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [47]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Also stated in: § Qualitative Analysis · plain
The paper relies on this without support.
Clinician diary entries accurately reflect actual changes in care and knowledge of the patient.
“Clinicians then completed a structured diary entry for each patient who completed the social needs survey.”
“Clinicians reported in their postencounter diary entries that the social needs survey helped change care in 22.5% of encounters (Table 2).”
The paper relies on this without support.
The social needs survey accurately identifies patients who have social needs.
“The social needs survey is provided in Table 1. We found that 86.2% of patients screened positive in at least 1 of the 16 domains.”
“although our social needs survey (Appendix A) is derived from NAM’s social needs measures and the Hennepin County Lifestyle Survey, it is not a validated instrument.”
The paper relies on this without support.
Patients' self-reported desire for help accurately reflects their need for assistance.
“patients were also asked whether or not they wanted help with each domain.”
“However, only 3.3% of patients wanted help in any domains.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Social risk data collected at the point of care can meaningfully influence indicators of care quality.
“Some recent studies have subsequently indicated that social risk data collected at the point of care can in fact meaningfully influence indicators of care quality.”
From Revising the logic model behind health care's social care investments (2024) · cites this paper as [49]
In a qualitative study, clinicians reported that knowing about patients' social risks changed care delivery decisions in 23% of patient encounters and helped improve interactions with and knowledge of the patient in 53% of encounters.
“In a qualitative study with clinicians who were provided social risk information about their patients, participants reported that knowing about patients’ social risks changed care delivery decisions in 23% of patient encounters and helped improve interactions with and knowledge of the patient in 53% of encounters. 49”
From Revising the logic model behind health care's social care investments (2024) · cites this paper as [49]
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Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? Yes.
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Prioritizing Paperwork Over Patient Care: Why Can't We Do Both?
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Screening for Social Determinants of Health in Michigan Health Centers
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Cold-Spotting: Linking Primary Care and Public Health to Create Communities of Solution
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Establishing an AHRQ Learning Collaborative: A White Paper
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Virani, S. S., Newby, L. K., Arnold, S. V., Bittner, V., Brewer, L. C., Demeter, S. H., Dixon, D. L., Fearon, W. F., Hess, B., Johnson, H. M., et al. (2023) · Circulation · doi:10.1161/cir.0000000000001168 · Cited by 1,598 · see citing works
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Part II: a qualitative study of social risk screening acceptability in patients and caregivers
Byhoff, E., De Marchis, E. H., Hessler, D., Fichtenberg, C., Adler, N., Cohen, A. J., Doran, K. M., Ettinger de Cuba, S., Fleegler, E. W., Gavin, N., et al. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.016 · Cited by 255 · see citing works
“Some surveyed clinicians reported that it was not their responsibility to screen for and address social adversity and expressed concern that asking personal questions about patients’ social circumstances could undermine trust between patients and clinicians.(22,23,34) Participants in our study suggested the opposite i…”
BackgroundSchickedanz, A. B., Hamity, C., Rogers, A., Sharp, A. L., & Jackson, A. H. (2019) · Medical Care · doi:10.1097/mlr.0000000000001051 · Cited by 225 · see citing works
Part I: a quantitative study of social risk screening acceptability in patients and caregivers
De Marchis, E. H., Hessler, D., Fichtenberg, C., Adler, N., Byhoff, E., Cohen, A. J., Doran, K. M., Ettinger de Cuba, S., Fleegler, E. W., Lewis, C. C., et al. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.010 · Cited by 194 · see citing works
“Successful screening implementation in select settings may suggest that patients do not object to screening, though some clinicians have expressed concerns about time constraints(38) and the potential for increasing patient stigma.(36,39,40) Prior studies on feasibility and acceptability of social screening are limite…”
Screening and Interventions for Social Risk Factors
Eder, M. L., Henninger, M. L., Durbin, S., Iacocca, M. O., Martin, A., Gottlieb, L. M., & Lin, J. S. (2021) · JAMA · doi:10.1001/jama.2021.12825 · Cited by 176 · see citing works
Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review
Henrikson, N. B., Blasi, P. R., Dorsey, C. N., Mettert, K. D., Nguyen, M. B., Walsh‐Bailey, C., Macuiba, J., Gottlieb, L. M., & Lewis, C. C. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.012 · Cited by 170 · see citing works
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“In postvisit diaries, the providers noted that having social information improved interactions with more than half of their patients; the providers reported using the social data in almost a quarter of care plans, including by being more mindful of medication costs and remembering to offer transportation services (Ton…”
BackgroundCottrell, E. K., Hendricks, M., Dambrun, K., Cowburn, S., Pantell, M., Gold, R., & Gottlieb, L. M. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.16852 · Cited by 126 · see citing works
Cottrell, E. K., Dambrun, K., Cowburn, S., Mossman, N., Bunce, A. E., Marino, M., Krancari, M., & Gold, R. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.014 · Cited by 111 · see citing works
Do Patients Want Help Addressing Social Risks?
Marchis, E. H. D., Alderwick, H., & Gottlieb, L. M. (2020) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2020.02.190309 · Cited by 109 · see citing works
Improving Social Needs Intervention Research: Key Questions for Advancing the Field
Fichtenberg, C., Alley, D. E., & Mistry, K. B. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.018 · Cited by 98 · see citing works
Marchis, E. H. D., Hessler, D., Fichtenberg, C., Fleegler, E. W., Huebschmann, A. G., Clark, C. R., Cohen, A. J., Byhoff, E., Ommerborn, M. J., Adler, N. E., et al. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.21201 · Cited by 84 · see citing works
Capacity to Address Social Needs Affects Primary Care Clinician Burnout
Kung, A., Cheung, T., Knox, M. J., Willard‐Grace, R., Halpern, J., Olayiwola, J. N., & Gottlieb, L. M. (2019) · The Annals of Family Medicine · doi:10.1370/afm.2470 · Cited by 82 · see citing works
Wallace, A. S., Luther, B. L., Sisler, S. M., Wong, B. G., & Guo, J. (2021) · Implementation Science Communications · doi:10.1186/s43058-021-00212-y · Cited by 74 · see citing works
Food Insecurity and Major Diet-Related Morbidities in Migrating Children: A Systematic Review
Dondi, A., Piccinno, V., Morigi, F., Sureshkumar, S., Gori, D., & Lanari, M. (2020) · Nutrients · doi:10.3390/nu12020379 · Cited by 70 · see citing works
If social determinants of health are so important, shouldn’t we ask patients about them?
Moscrop, A., Ziébland, S., Bloch, G. C., & Iraola, J. R. (2020) · BMJ · doi:10.1136/bmj.m4150 · Cited by 63 · see citing works
Revising the logic model behind health care's social care investments
GOTTLIEB, L. M., HESSLER, D., WING, H., GONZALEZ‐ROCHA, A., CARTIER, Y., & FICHTENBERG, C. (2024) · The Milbank Quarterly · doi:10.1111/1468-0009.12690 · Cited by 64 · see citing works
“49 The study did not examine subsequent health outcomes, but others have.”
Byhoff, E., Garg, A., Pellicer, M., Diaz, Y., Yoon, G. H., Charns, M. P., & Drainoni, M. (2019) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2019.03.180276 · Cited by 61 · see citing works
Uses and Misuses of Patient- and Neighborhood-level Social Determinants of Health Data
Gottlieb, L. M., Francis, D., & Beck, A. F. (2018) · The Permanente Journal · doi:10.7812/tpp/18-078 · Cited by 59 · see citing works
Nkambule, S. J., Moodley, I., Kuupiel, D., & Mashamba-Thompson, T. P. (2021) · Scientific Reports · doi:10.1038/s41598-021-84344-0 · Cited by 53 · see citing works
Living in “Cold Spot” Communities Is Associated with Poor Health and Health Quality
Liaw, W., Krist, A., Tong, S. T., Sabo, R., Hochheimer, C. J., Rankin, J. L., Grolling, D., Grandmont, J., & Bazemore, A. (2018) · Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2018.03.170421 · Cited by 51 · see citing works
“In an accompanying mixed methods study, we provided clinicians with information about patient neighborhoods and individual needs and found that having the information increased clinician awareness about social needs and the amount and type of patient education delivered.(42) Others have outlined the specific questions…”
MethodSelf-citationHessler, D., Bowyer, V., Gold, R., Shields-Zeeman, L., Cottrell, E. K., & Gottlieb, L. (2019) · Current Diabetes Reports · doi:10.1007/s11892-019-1149-y · Cited by 50 · see citing works
Russell, L. E., Cohen, A. J., Chrzas, S., Halladay, C. W., Kennedy, M. A., Mitchell, K., Moy, E. M., & Lehmann, L. S. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-023-08181-9 · Cited by 49 · see citing works
The ‘ what’ and ‘ how ’ of screening for social needs in healthcare settings: a scoping review
Karran, E. L., Cashin, A. G., Barker, T., Boyd, M. A., Chiarotto, A., Dewidar, O., Petkovic, J., Sharma, S., Tugwell, P., & Moseley, G. L. (2023) · PeerJ · doi:10.7717/peerj.15263 · Cited by 44 · see citing works
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“Other studies found that knowing patients’ social needs not only improved patient-provider communications but also changed what clinicians do [23], such as providing more exercise and dietary counseling, being mindful of medication costs when prescribing, and helping with transportation to access to clinics.”
BackgroundInfluentialPinto, A. D., Bondy, M., Rucchetto, A., Ihnat, J., & Kaufman, A. (2019) · Family Practice · doi:10.1093/fampra/cmy129 · Cited by 42 · see citing works
“A recent study of primary care physicians in Virginia, USA similarly found that assessing social needs can be resource intensive and there is an important need to engage the entire team (37).”
BackgroundNowak, D. A., & Mulligan, K. (2021) · Canadian Family Physician · doi:10.46747/cfp.670288 · Cited by 42 · see citing works
Implementing social interventions in primary care
Bloch, G. C., & Rozmovits, L. (2021) · Canadian Medical Association Journal · doi:10.1503/cmaj.210229 · Cited by 39 · see citing works
Caicedo, N. M. A., Parry, E. L., Arslan, N., & Park, S. E. (2023) · BJGP Open · doi:10.3399/bjgpo.2023.0155 · Cited by 35 · see citing works
Prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO)
Schiavoni, K. H., Helscel, K., Vogeli, C., Thorndike, A. N., Cash, R. E., Camargo, C. A., & Samuels‐Kalow, M. E. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08721-9 · Cited by 33 · see citing works
Sokol, R. L., Mehdipanah, R., Bess, K., Mohammed, L., & Miller, A. L. (2021) · Journal of Pediatric Health Care · doi:10.1016/j.pedhc.2021.05.002 · Cited by 30 · see citing works
Gold, R. B., Sheppler, C. R., Hessler, D., Bunce, A., Cottrell, E., Yosuf, N., Pisciotta, M., Gunn, R., Leo, M. C., & Gottlieb, L. M. (2021) · JMIR Research Protocols · doi:10.2196/31733 · Cited by 29 · see citing works
Provider Impacts of Socioeconomic Risk Screening and Referral Programs: A Scoping Review
Quiñones‐Rivera, A., Wing, H. E., Barr‐Walker, J., Yee, M. D., Harrison, J. M., & Gottlieb, L. M. (2021) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2021.04.210039 · Cited by 32 · see citing works
“Providers in 2 post-only studies primarily expressed hesitation with utility to patient care.(34,54) In”
BackgroundPatient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings
Tung, E. L., Marchis, E. H. D., Gottlieb, L. M., Lindau, S. T., & Pantell, M. S. (2021) · Journal of General Internal Medicine · doi:10.1007/s11606-020-06484-9 · Cited by 31 · see citing works
Krist, A. H., Davidson, K. W., Ngo‐Metzger, Q., & Mills, J. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.013 · Cited by 29 · see citing works
Self-citationImplementing Health Related Social Needs Screening in an Outpatient Clinic
Nohria, R., Xiao, N.-Z., Guardado, R., Drainoni, M., Smith, C., Nokes, K., & Byhoff, E. (2021) · Journal of Primary Care & Community Health · doi:10.1177/21501319221118809 · Cited by 21 · see citing works
How Hypertension Guidelines Address Social Determinants of Health
Razon, N., Hessler, D., Bibbins-Domingo, K. B., & Gottlieb, L. M. (2021) · Medical Care · doi:10.1097/mlr.0000000000001649 · Cited by 32 · see citing works
Predmore, Z., Hatef, E., & Weiner, J. P. (2019) · Population Health Management · doi:10.1089/pop.2018.0151 · Cited by 24 · see citing works
“15,16 Use case 2: predictive risk modeling within delivery systems The 2 applications at the level of delivery system (eg, health plan, integrated delivery system) include ‘‘social and behavioral predictive modeling’’ for high-risk case finding and SDoH adjustment for reimbursements and other…”
Advancing the Science of Implementation in Primary Health Care
Bazemore, A., Neale, A. V., Lupo, P., & Seehusen, D. A. (2018) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2018.03.180091 · Cited by 26 · see citing works
Self-citationPatel, M. R., Tolentino, D. A., Smith, A. L., & Heisler, M. (2023) · Preventive Medicine Reports · doi:10.1016/j.pmedr.2023.102246 · Cited by 26 · see citing works
Social workers are key to addressing social determinants of health in integrated care settings
Petruzzi, L. J., Milano, N., Chen, Q., Noel, L., Golden, R., & Jones, B. L. (2023) · Social Work in Health Care · doi:10.1080/00981389.2023.2292565 · Cited by 24 · see citing works
“In clinics or hospitals that have implemented SDH assessment tools, there is often a lack of capacity to identify resources, make referrals and systematically follow-up with socially complex patients (Garg et al., 2016; Schickedanz et al., 2019; Schwartz et al., 2020; Tong et al., 2018).”
BackgroundParry, J. E., Vanstone, M. G., Grignon, M., & Dunn, J. R. (2021) · International Journal for Equity in Health · doi:10.1186/s12939-021-01546-8 · Cited by 25 · see citing works
Patient Interest in Receiving Assistance with Self-Reported Social Risks
Gruß, I., Varga, A. M., Brooks, N. B., Gold, R. B., & Banegas, M. P. (2021) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2021.05.210069 · Cited by 22 · see citing works
Social Needs of Patients Undergoing Total Joint Arthroplasty
Norris, A. C., Mears, S. C., Siegel, E. R., et al. (2022) · The Journal of Arthroplasty · doi:10.1016/j.arth.2021.11.019 · Cited by 24 · see citing works
Receipt of Social Needs Assistance and Health Center Patient Experience of Care
Nguyen, K. H., Trivedi, A. N., & Cole, M. B. (2020) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2020.08.030 · Cited by 22 · see citing works
Peahl, A. F., TURRENTINE, M. A., Srinivas, S. K., King, T. L., & Zahn, C. M. (2023) · Obstetrics and Gynecology Clinics of North America · doi:10.1016/j.ogc.2023.03.002 · Cited by 21 · see citing works
Geographic Characteristics of Loneliness in Primary Care
Tong, S. T., Mullen, R. A., Hochheimer, C. J., Sabo, R., Liaw, W. R., Nease, D. E., Krist, A. H., & Frey, J. (2019) · The Annals of Family Medicine · doi:10.1370/afm.2364 · Cited by 20 · see citing works
Self-citationAn Adaptive, Contextual, Technology‐Aided Support (ACTS) System for Chronic Illness Self‐Management
GLASGOW, R. E., HUEBSCHMANN, A. G., KRIST, A. H., & DEGRUY, F. V. (2019) · The Milbank Quarterly · doi:10.1111/1468-0009.12412 · Cited by 18 · see citing works
Self-citationDesRoches, C. M., Wachenheim, D., Garcia, A., Harcourt, K., Henry, J. L., Shah, R., & Patel, V. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.44376 · Cited by 19 · see citing works
Adekoya, I., Delahunty‐Pike, A., Howse, D., et al. (2023) · BMC Family Practice · doi:10.1186/s12875-023-02173-8 · Cited by 17 · see citing works
Cohen, A. J., Isaacson, N. F., Torby, M., Smith, A. L., Zhang, G., & Patel, M. R. (2022) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2022.02.022 · Cited by 18 · see citing works
Livingston, C. J., Titus, T. M., Yerokun, T. A., & Patel, N. M. (2025) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2025.01.005 · Cited by 18 · see citing works
Langevin, R., Berry, A. B. L., Zhang, J., Fockele, C. E., Anderson, L., Hsieh, D. T., Hartzler, A. L., Duber, H. C., & Hsieh, G. (2023) · Applied Clinical Informatics · doi:10.1055/a-2035-5342 · Cited by 16 · see citing works
Kazi, S., Starling, C. M., Milicia, A. P., Buckley, B. O., Grisham, R., Gruber, E., Miller, K., & Arem, H. E. (2024) · Frontiers in Health Services · doi:10.3389/frhs.2024.1380589 · Cited by 16 · see citing works
“Our fi ndings of provider-level barriers such as perceptions of the limited utility of asking patients about social needs in a medical setting have been previously reported (16, 17, 26, 27).”
BackgroundHartzler, A. L., Xie, S. J., Wedgeworth, P., Spice, C., Lybarger, K., Wood, B. R., Duber, H. C., Hsieh, G., Singh, A., SDoH Community Champion Advisory Board, et al. (2023) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocad043 · Cited by 15 · see citing works
Krist, A. H., O'Loughlin, K. M., Woolf, S. H., Sabo, R., Hinesley, J., Kuzel, A. J., Rybarczyk, B. D., Kashiri, P. L., Brooks, E. M., Glasgow, R. E., et al. (2020) · Trials · doi:10.1186/s13063-020-04463-3 · Cited by 14 · see citing works
Self-citationIntegrating Social Needs into Health Care: An Implementation Science Perspective
Kepper, M. M., Walsh‐Bailey, C., Owens-Jasey, C., Gunn, R., & Gold, R. B. (2024) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-071823-111332 · Cited by 18 · see citing works
“Provider awareness of the impact of social needs on patients and perceptions that screening is appropriate and beneficial and can improve care are prominent facilitators (27, 41, 43, 51, 54, 62, 63, 72, 75, 89, 90, 92).”
InfluentialThe role of health-related quality of life in improving cancer outcomes.
Nolazco, J. I., & Chang, S. L. (2023) · PubMed · Cited by 14 · see citing works
A Fair Individualized Polysocial Risk Score for Identifying Increased Social Risk in Type 2 Diabetes
Huang, Y., Guo, J., Donahoo, W. T., Lee, Y. A., Fan, Z., Lu, Y., Chen, W.-H., Tang, H., Bilello, L., Saguil, A. A., et al. (2024) · Nature Communications · doi:10.1038/s41467-024-52960-9 · Cited by 14 · see citing works
“First, existing screening tools are not automated, making them dif fi cult to adapt to clinical work fl ows 18,19 .”
BackgroundMethodSocial needs screening in primary care: A tool in the fight for health equity?
Painter, H., Parry, E., McCann, L., Dehn Lunn, A., & Ford, J. (2024) · Public Health in Practice · doi:10.1016/j.puhip.2024.100466 · Cited by 13 · see citing works
“Time constraints, physician discomfort or lack of expertise are frequently cited reasons for not screening [30,31].”
BackgroundPartner-developed electronic health record tools to facilitate social risk-informed care planning
Gunn, R., Pisciotta, M., Gold, R. B., Bunce, A., Dambrun, K., Cottrell, E., Hessler, D., Middendorf, M., Alvarez, M., Giles, L., et al. (2023) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocad010 · Cited by 15 · see citing works
Adepoju, O. E., Liaw, W. R., Patel, N. C., Rastegar, J. S., Ruble, M. W., Franklin, S. M., Renda, A. M., Obasi, E. M., & Woodard, L. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.39855 · Cited by 14 · see citing works
Self-citationBambekova, P. G., Liaw, W. R., Phillips, R. L., et al. (2020) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2020.03.190206 · Cited by 13 · see citing works
“Minorities have poorer outcomes due to higher levels of medical risk, worse living environments, and greater challenges in adherence and lifestyle;(6) at the same time, providers serving these beneficiaries may have poorer performance due to fewer resources, more challenging clinical workloads, and lower levels of com…”
BackgroundSelf-citationEuropean Forum for Primary Care: Position Paper for Primary Care Mental Health
Smit, D., Hill, L., Walton, I., Kendall, S. A., & Lepeleire, J. D. (2020) · Primary Health Care Research & Development · doi:10.1017/s1463423620000304 · Cited by 12 · see citing works
“Nurture, love, support, and freedom to grow are necessary to develop into a healthy adult, but those born in poorer families and poorer areas have an increased risk of mental health problems in later life (Vannieuwenborg et al., 2015; Tong et al., 2018).”
BackgroundAccess to primary health care: perspectives of primary care physicians and community stakeholders
Toal-Sullivan, D., Dahrouge, S., Tesfaselassie, J., & Olejnik, L. J. (2024) · BMC Family Practice · doi:10.1186/s12875-024-02312-9 · Cited by 16 · see citing works
“This influences providers’ ability to adopt a holistic approach to person-centered care including eliciting patients’ concerns and addressing their social challenges [16, 21–23].”
BackgroundBrown, J. D., Ahmed, N., Biel, M. G., Patchen, L., Rethy, J. A., Thomas, A., & Arem, H. E. (2023) · PLoS ONE · doi:10.1371/journal.pone.0283815 · Cited by 12 · see citing works
“A implementation study in 12 primary care practices in Virginia also highlighted the intensive nature of social needs screening in standard care and challenges in providing resources to address identified needs [38].”
BackgroundByhoff, E., Marchis, E. H. D., Gottlieb, L. M., Halperin-Goldstein, S., Nokes, K., & LeClair, A. M. (2020) · Journal of Immigrant and Minority Health · doi:10.1007/s10903-020-01005-6 · Cited by 13 · see citing works
Bunce, A., Donovan, J., Hoopes, M. J., Gottlieb, L. M., Krancari, M., & Gold, R. B. (2023) · The Annals of Family Medicine · doi:10.1370/afm.2953 · Cited by 12 · see citing works
Fiori, K., Levano, S. R., Haughton, J., Whiskey-Lalanne, R., Telzak, A., Hodgson, S., Spurrell-Huss, E., & Stark, A. (2023) · Journal of Clinical and Translational Science · doi:10.1017/cts.2023.652 · Cited by 11 · see citing works
Steeves-Reece, A. L., Nicolaidis, C., Richardson, D. M., Frangie, M., Gomez-Arboleda, K., Barnes, C., Kang, M., Goldberg, B. W., Lindner, S., & Davis, M. M. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191912668 · Cited by 11 · see citing works
“The prevalence of phone-based HRSN screening and referral interventions is increasing due to both the COVID-19 [11,27,29] pandemic and concerns about time constraints during clinical visits [49–53].”
BackgroundNurses’ work at Family Health Strategy: possibilities to operate health needs
Rodríguez, A. M. M. M., Mishima, S. M., Lettiere-Viana, A., et al. (2020) · Revista Brasileira de Enfermagem · doi:10.1590/0034-7167-2019-0704 · Cited by 11 · see citing works
“Especially of social determinants, taken as conditions of different natures that interfere in their way of being, living and becoming ill(2).”
BackgroundHospitals' collection and use of data to address social needs and social determinants of health
Richwine, C., & Meklir, S. (2024) · Health Services Research · doi:10.1111/1475-6773.14341 · Cited by 11 · see citing works
Patel, M. R., Zhang, G., Heisler, M., Piette, J. D., Resnicow, K., Choe, H. M., Shi, X., & Song, P. X. ‐. (2024) · Journal of General Internal Medicine · doi:10.1007/s11606-024-08708-8 · Cited by 12 · see citing works
Jih, J., Nguyen, A., Cenzer, I. S., & Morrish, J. (2023) · BMC Family Practice · doi:10.1186/s12875-023-02125-2 · Cited by 11 · see citing works
“Identifying and addressing the unmet social needs of patients in clinical settings could not only lower healthcare utilization and cost but could allow for delivery of healthcare that is more person-centered and result in more equitable health outcomes [7–9].”
BackgroundUtilizing PHATE: A Population Health–Mapping Tool to Identify Areas of Food Insecurity
Lichkus, J., Liaw, W. R., & Phillips, R. L. (2019) · The Annals of Family Medicine · doi:10.1370/afm.2387 · Cited by 10 · see citing works
Self-citationFamily Medicine Team Perspectives on Screening for Health-Related Social Needs
Porterfield, L. R., Jan, Q. H., Jones, F., Cao, T., Davis, L., Guillot-Wright, S. P., & Walcher, C. M. (2024) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2023.230167r3 · Cited by 9 · see citing works
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“13,17 To explore these important concerns, we conducted an exploratory study (similar to the Exploration phase in the Exploration, Preparation, Implementation, Sustainment framework 18 ) with the primary objective to understand how patients perceived social and behavioral risk screening.”
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Food Insecurity Prevalence and Risk Factors at a Large Academic Medical Center in Michigan
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Patient Preferences for Discussing and Acting on Health-Related Needs in Primary Care
O'Loughlin, K. M., Shadowen, H. M., Haley, A. D., Gilbert, J., Kashiri, P. L., Webel, B., Huebschmann, A. G., & Krist, A. H. (2022) · Journal of Primary Care & Community Health · doi:10.1177/21501319221115946 · Cited by 8 · see citing works
Self-citationDigital Health Technologies for Screening and Identifying Unmet Social Needs: Scoping Review
Sezgın, E., Jackson, D. I., Boch, S. J., Davenport, M., Skeens, M. A., Dolcé, M., Frankin, B., Militello, L. K., Lyman, E., Kelleher, K. J., et al. (2025) · Journal of Medical Internet Research · doi:10.2196/78793 · Cited by 6 · see citing works
“Furthermore, DHT can extend support beyond clinical settings by helping patients and families connect with essential resources, thereby ensuring continuous support and enhancing overall well-being [22,23].”
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“Increasing in-person or telephone follow-up, however, may be challenging given that screening and referral for social needs is often already a resource-intensive and time-consuming process for providers [39,40].”
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“And physicians in primary care are tasked to understand and address the concerns and needs from patients (27, 28).”
Health-Related Social Needs Discussions in Primary Care Encounters in Safety-Net Clinics
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Addressing Equity and Social Needs: The New Frontier of Patient Engagement Research
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When and How Do We Need Permission to Help Patients Address Social Risk?
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“social risk screening questionnaires or asking about the social, economic, and behavioral risk factors of their patients in other ways.(1,2) In their commentary in this issue, De Marchis et al (2020) describe the rapid proliferation of these efforts, supported by”
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“16,17 However, while systematic screening surveys can inform clinicians’ knowledge about their patients’ SDoH, they may not replace the valuable information and rapport building that occurs when clinicians acquire BSH directly from their patients, either through purposeful questions or small talk.”
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Self-citation
- Authors
- Tong, S. T., Liaw, W. R., Kashiri, P. L., Pecsok, J., Rozman, J., Bazemore, A. W., & Krist, A. H.
- Affiliations
- Virginia Commonwealth University (US)
- ORCID
- Venue
- The Journal of the American Board of Family Medicine
- Published
- 2018-05
- Volume
- 31
- Issue
- 3
- Pages
- 351-363
- ISSN
- 1557-2625 (ISSN-L)
- 1558-7118
- PMC
- PMC6497466
- OpenAlex
- W2799417257
- Cited by
- 173
- References
- 41
- Citations by year
- 2026: 17 · 2025: 22 · 2024: 22 · 2023: 28 · 2022: 22 · 2021: 22 · 2020: 15 · 2019: 20 · 2018: 5
- FWCI
- 16.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of the American Board of Family Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Virginia Commonwealth University (UL1TR000058)
- National Institutes of Health (UL1TR002649, UL1TR000058)
- Center for Clinical and Translational Research (UL1TR000058)
- National Center for Advancing Translational Sciences
- Topics
- Social Sciences › Health › Health disparities and outcomes
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Social Sciences › Health › Public Health and Social Inequalities
- Keywords
- social needs screening, social determinants of health, primary care providers, clinician experience, social needs assessment, low-income patients, housing insecurity, food access, transportation barriers, substance use, clinician-patient communication, learning collaborative, resource constraints
- MeSH terms
- Adult, Communication, Female, Health Services Needs and Demand, Humans, Male, Primary Health Care, Prospective Studies, Quality of Life, Surveys and Questionnaires, Socioeconomic Factors, Virginia, Needs Assessment, Young Adult, Physicians, Primary Care, Social Determinants of Health
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