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

Kevin Fiori, Milani Patel, Dana Sanderson, Amanda Parsons, Sybil Hodgson, Jenna Scholnick, Eleanor Bathory, Tanya White-Davis, Neal Wigod, Tashi Chodon, Andrea Rich, Sandra Braganza

Research output: Contribution to journalArticle


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.

Original languageEnglish (US)
JournalJournal of Primary Care and Community Health
StatePublished - Jan 1 2019



  • community health workers
  • implementation
  • improvement
  • pediatrics
  • quality
  • social determinants of health

ASJC Scopus subject areas

  • Community and Home Care
  • Public Health, Environmental and Occupational Health

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