Introduction
Social needs screeners (SNS) are becoming more commonplace in primary care [Reference Painter, Parry, McCann, Dehn Lunn and Ford1]. As a tool meant to identify the social determinants of health (SDOH) impacting patients’ health outcomes, health care providers see value in using SNS data for developing care plans that keep the SDOH in mind [Reference Chung, Siegel and Garg2–Reference Trinacty, LaWall, Ashton, Taira, Seto and Sentell4]. Despite their potential to provide more insight into patients’ lives outside the clinic, SNS are underutilized in primary care. The literature suggests that SNS are utilized in up to 30% of patient encounters [Reference Pinto, Bondy, Rucchetto, Ihnat and Kaufman5,Reference Schickedanz, Hamity, Rogers, Sharp and Jackson6]. Reasons for low SNS utilization include limited integration of SNS into clinic workflows, workforce capacity issues, and resource availability to address identified social needs. For instance, healthcare administrators and providers are concerned about SNS being inappropriately integrated into the clinic workflow, thereby impacting wait times. Integration into electronic health record (EHR) infrastructures is another area of concern related to administration of SNS [Reference Drake, Batchelder and Lian7–Reference Vasan, Kenyon and Palakshappa10]. Health care providers in a study on SNS integration in emergency departments hope the information is available in the EHR in real time [Reference Loo, Molina and Ahmad11]. Workforce capacity issues are related to identifying the health care provider or staff best equipped to assist with SNS administration and the referral process [Reference Page-Reeves, Kaufman and Bleecker12]. Finally, resource availability is a major concern within health systems. Among health care professionals and patients, the resounding sentiment is that SNS need to be followed up with action [Reference Hamity, Jackson, Peralta and Bellows3,Reference Tong, Liaw and Kashiri13]. In that vein, providers report being hesitant to implement SNS due to a lack of knowledge about the community resources available [Reference Vasan, Kenyon and Palakshappa10].
In addition to using information from SNS to help develop care plans for patients, it is equally important for primary care facilities to establish referral systems to connect patients to needed services in their communities [Reference Fraze, Beidler and Gottlieb14,Reference Lian, Kutzer and Gautam15]. Examples of services include food boxes from local food banks, gas cards, and grocery store cards. However, resource availability is a major concern as primary care providers and staff do not know the capacity of these organizations to take on these SDOH issues, nor do they feel like they are best equipped to refer patients in an appropriate and efficient manner to these resources. Additional needs can involve legal aspects such as accessing and obtaining health insurance, appealing the denial of health care services, and applying for public benefits. A potential resource to address such needs is medical–legal partnerships (MLPs), where patients with social needs can receive free or low-cost legal services [Reference Tobin-Tyler and Teitelbaum16]. People who work at MLPs can assist with things like advanced care directives, medical bill disputes, and assistance applying for public benefits [Reference Tobin-Tyler and Teitelbaum16].
MLPs can address social needs through cooperation between health care providers, social service organizations, and attorneys or law students. MLPs can be housed in health care systems, legal aid organizations, and law schools [Reference Johnson, Asay and Keegan17,Reference Nerlinger, Alberti and Gilbert18]. This resource could more comprehensively address numerous social needs that a person may experience that can be addressed through legal representation and advocacy [Reference Tobin-Tyler and Teitelbaum16,Reference Sauaia, Santos, Scanlon, Farley and Dean19]. Despite evidence that MLPs can be effective in addressing social needs, these resources are, like SNS themselves, underutilized [Reference Beeson, Mcallister and Regenstein20].
To ascertain the best way to integrate new protocols into and understand the intricacies of clinic workflows, practitioners and researchers use process mapping [Reference Heher and Chen21]. A process map is a quality improvement tool that documents the action steps of facilities to identify barriers for integrating a new protocol, technology, or activity [Reference Heher and Chen21]. While process mapping can be performed in a multitude of ways, there are five phases: preparation, data and information gathering, map generation, process analysis, and brainstorm solutions [Reference Antonacci, Lennox, Barlow, Evans and Reed22]. At each stage, members of the health care facility engage with the process, marking the cornerstone of process mapping [Reference Antonacci, Reed, Lennox and Barlow23]. Applied in primary care facilities, process mapping helps to narrow strategies for implementation [Reference Hoefsmit, Schretlen, Does, Verouden and Zandbergen24]. For example, in a recent study using process mapping to implement patient navigation for people with breast cancer, the tool outlined the intricacies of clinic workflows, identified gaps and areas for process improvement, and was found to serve as a starting point for future evidence-based strategy implementation [Reference Casanova, LeClair and Xiao25]. Using a process mapping approach, this paper aims to identify the barriers and facilitators of integrating SNS and MLPs into the clinic workflow of primary care facilities.
Methods
Study population and procedures
Eleven primary care providers and clinic staff were recruited from three different healthcare systems in Pennsylvania through convenience and snowball sampling. Sample size was determined based on when data saturation was reached. In qualitative research, multiple studies on methodology have shown that data saturation can be reached with a minimum of 9 interviews. Per a recent systematic review, a common range for achieving data saturation is 9–17 interviews [Reference Hennink and Kaiser26]. Participants were eligible if they were physicians (i.e., MD, DO), physician assistants, nurses (i.e., CRNP, LRN, RN), patient navigators, medical assistants, or those who support clinical work in internal medicine or family medicine. Eligible participants were required to read and write English. Recruitment emails were sent inviting participants to complete the consent form, screening questions, a brief survey to assess familiarity with SNS and MLPs, and identify their availability for a 45-minute interview. The emails included a link to a Research Electronic Data Capture (REDCap) questionnaire to verify eligibility and provide consent. Once participants completed the study activities, they were offered a $50 e-gift card. The protocol for this study was approved by the Pennsylvania State University’s Institutional Review Board on December 17, 2024 (STUDY00025635).
Process mapping interviews
Interviews were conducted by the lead author (JG) using a semi-structured interview guide. The interview guide was developed based on an idealized process map informed by shadowing primary care practitioners, case managers, and social workers to understand current patient workflows and referral practices. Participants were presented with an idealized process map (Figure 1). Additional barriers and facilitators elicited during the interviews were added to the process map by co-authors NS and JL. Participants were asked to identify changes in the process map to match what their primary care site does related to SNS. After creating the process map of the individuals’ sites, participants walked through the swim lanes of the process map. Questions were organized into four swim lanes: planning, patient-provider interaction, referrals, and MLPs. Planning questions asked about what screener, if any, was used and the perceived effectiveness of the screener to capture patients’ SDOH information. In the patient-provider interaction lane, participants were asked to describe how they engage with the patient about their SNS results. Non-clinician participants were asked about how SNS were integrated into EHRs. Questions in the referrals lane pertained to processes for referring patients to resources, located internally and externally, to address their social needs and whether they see the needs being met. Clinician participants discussed their relationship with social workers and community health workers. Non-clinician participants described their methods for referring patients. Finally, in the MLP lane, participants were asked to identify the barriers to integrating legal representation as a resource for addressing social needs. This swim lane included gathering information about the MLPs interactions with the members of clinical staff. This includes education and training needs for health care professionals on the use of MLPs in addressing social needs and the amount of communication required between the legal representative and the health care professional.
Figure 1. Idealized process map. Ovular shapes in the figure denote the start or end of the process. Hexagonal shapes in the process map identify where planning and preparation take place. Squares are general steps the move the process forward. When documentation is produced, the freeform shape is used. Finally, the diamond shape is a trigger to proceed with the process. Without the diamond shape, the process map ends [Reference Ruiz27].
Data analysis
A methodological, philosophical assumption was used to guide the analysis. This assumption is grounded in the concept that every participant’s experience with, attitudes about, and opinions around SNS will converge into generalizations. Development of these thematic generalizations used a pragmatic approach to identify actionable implementation strategies.
Analysis was guided by the Consolidated Framework for Implementation Research (CFIR). This framework was selected because it was best suited for identifying the multi-level factors behind implementing SNS and MLPs into clinic workflows. The goal was that each theme that arose from the interviews could be connected to a CFIR construct (e.g., Partnerships and Connections, Innovation Adaptability, and Relative Priority) and inform future implementation efforts [Reference Damschroder, Reardon, Widerquist and Lowery28]. Immediately after each interview, JG and the secondary facilitator, would reorganize the steps of the process map to match the current processes of the participant’s clinic workflow. Additionally, a line of delineation was identified to symbolize where the actual process ends, and the idealized process would begin. After the interviews were transcribed verbatim, data was coded inductively by JG and the facilitators, independently. Upon reading the transcripts, major themes were extrapolated among the four swim lanes. Information from the major themes was then matched to CFIR constructs to identify determinants of implementation (Table 1).
Table 1. Identified themes through thematic analysis
Results
Among the eleven participants, four were physicians, four were social workers, two were non-clinical staff, and one was a nurse. These participants came from eleven different primary care sites, representing one academic health system and two federally qualified health center (FQHC) systems. All participants were familiar with SNS, but only seven were familiar with MLPs.
Themes are presented for each swim lane of the process map. Examples of participant quotes have been included to illuminate their perspectives. Alongside participants’ quotes are their titles and health care setting type. Themes were matched to constructs found in the CFIR.
Planning phase
Theme 1: When planning for SNS integration into clinic workflow, having feedback from a range of providers and staff is necessary
Most participants agreed that assessing patients for social needs is valuable. However, the consensus about its effectiveness is questionable, as one participant expresses:
“I don’t know that I’ve necessarily gotten a lot of positives from it, but I don’t have any reason to think that it’s ineffective as a screening tool, but I certainly haven’t had a lot of positive results from it.” Participant 11 (Physician, Academic Health Center)
Before the SNS was implemented, participants emphasized the importance of tailoring its implementation to also consider clinic staff preferences.
“I would make sure that we get all the key informants… the social workers, the legal people, the clinic managers, the nurses, because they’re all going to be affected by this.” Participant 1 (Physician, Academic Health Center)
When asked about the next most feasible steps to integrating SNS, participants talked about engaging with the primary care providers themselves.
“You take a gauge of the room… You’re adding something else to [their] plate. So, making that process just flow with everything else that they’re doing is probably going to help.” Participant 4 (Education Program Specialist, Academic Health Center)
Theme 2: Review and adaptation of SNS should be regular
Once the key staff have been identified to support the SNS integration, review and adaptation are essential. Participants recognize that the needs of patients change over time. This requires SNS integration to include reflection and evaluation on processes to ensure its successful use.
“It needs to be updated, changed with the times if you would. I think that they’ve had the same questions on there probably for quite a while, and it really needs to be maybe – I used the word updated, but just reviewed and make sure that it’s on par with the needs of the society today…” Participant 6 (Nurse, Federally Qualified Health Center)
Important adaptations are offering SNS in different languages and modalities. The former facilitates culturally responsive, patient centered care.
“I think we serve people who speak over 40 different languages, a lot of different cultures. A lot of people I think almost 40% of our patient base speaks a language other than English, a lot of that being Spanish. And just different cultures and how they would react to questions like this.” Participant 7 (Director of Social Services, Federally Qualified Health Center)
Health literacy can pose a barrier to patients when answering SNS. Participants said that asking questions verbally can be helpful to patients’ completion of SNS.
“… if I’m in their home and I ask them, they seem to be a little more open about, about it.” Participant 6 (Nurse, Federally Qualified Health Center)
The major barrier for adapting SNS is the limitations of validated screeners like PRAPARE or WECARE. While the PRAPARE tool is offered in multiple languages, its implementation challenges rest on the costs associated with integrating other languages into health systems’ EHR systems. Initial start-up and maintenance can be cost prohibitive dependent upon the number of patients filling out the screener [Reference Drake, Reiter and Weinberger29]. If these tools are not translated into a language for the patient population, this barrier serves as an external pressure impacting screener completion.
“We can’t force [the screening program companies] to invent their program in a language that it doesn’t exist in” Participant 3 (Social Worker, Federally Qualified Health Center)
Theme 3: Providers differ on the frequency of screening based on population
One of the major barriers outlined by the participants was the frequency of screening patients for social needs. Among FQHCs, providers believe that screening may need to take place more often as their patient population may have higher prevalence of social needs like food insecurity or housing instability.
“I know that we check these once a year or every six months for our patients but trying to capture it more frequently for those higher risk populations is definitely a gap.” Participant 10 (Social Worker, Federally Qualified Health Center)
Participants in the academic health systems, on the contrary, prefer to ask screeners less frequently to avoid overwhelming patients. Given the number of screenings patients participate in, one interviewee discussed limiting how often patients complete SNS.
“They [the patients] only get the health lead screening [another screening tool] once per year just to try to cut down on how often they’re getting bombarded with screenings.” Participant 5 (Social Worker, Academic Health Center)
Additionally, certain conditions may warrant a patient being screened more often regardless of where they receive their care. One participant talked about screening pregnant patients more often because changes in social needs can impact their pregnancy.
“We’re working on a new workflow for our [obstetrics] patients and how we’re going to use social screeners and how they’re going to be assessed and things like that. Because I think sometimes, they get missed until it’s too late” Participant 10 (Social Worker, Federally Qualified Health Center)
Patient-provider interaction phase
Theme 4: Health care provider opinions differ on who should administer SNS and how often patients should be screened
When participants were asked about administering and using SNS during the patient visit, it was clear that the responsibility should be on other staff members, not physicians.
“The key thing is just to recognize that the patient provider interaction is full. The system has stuffed as much in there as will go…assuming that you’re going to be able to put more into that, is just destined to fail.” Participant 11 (Physician, Academic Health Center)
Most participants reported feeling confident in their ability to discuss patients’ SNS results but lack the necessary bandwidth and time to include another action item in the patient visit. This understanding is recognized among clinicians and non-clinicians.
“I also know that the providers are very limited on time…So that can be a little bit of a struggle, from the provider’s end.” Participant 6 (Social Worker, Federally Qualified Health Center)
“Time is always a barrier. How do we find the time to do that? How do we manage to shoehorn that in sometimes?” Participant 2 (Social Worker, Academic Health Center)
In relying on non-clinician staff, participants identify two barriers: lack of training and competing priorities. With front desk staff being identified as the most feasible SNS deliverers, participants believe that education and training would make administering SNS more consistent.
“Ideally, if we could have a person like our front office to potentially be trained a little bit better on recognizing if there’s a barrier with the screening, and maybe one helps the patient or connect them to an interpreter at that point to do the Health Leads screening.” Participant 3 (Social Worker, Federally Qualified Health Center)
There are multiple priorities that clinicians must consider when meeting with patients. The relative priority of SNS can be a major barrier to the effectiveness and sustainability of SNS implementation. With the number of priorities overwhelming primary care facilities, SNS can be set aside.
“So, when there’s a push to collect this information and it’s given priority and attention, they get done frequently. But then once other things, competing priorities, these questions, the screener doesn’t always get done on a regular basis” Participant 7 (Director of Social Services, Federally Qualified Health Center)
Theme 5: Investing in physical and information technology (IT) infrastructure would increase systematic SNS utilization, but there needs to be balance
Many participants believed that primary care facilities should have both the physical and IT infrastructure available to have patients answer SNS. Most participants believed that SNS should be automatically integrated into patient EHR with several recommending the use of tablets or phone apps.
“Everyone would get an iPad when they come in. They fill out the questions and then hit save and that would automatically update into the EHR that I could see and that the nurse could see and that the social worker could see.” Participant 5 (Physician, Academic Health Center)
This information would be automatically uploaded to the EHR and available for the health care professionals to see based on their needs. Participants want to view the results before engaging with the patient.
“It might be helpful to have something like an iPad questionnaire so that once it’s submitted, it can go directly into the patient’s chart.” Participant 8 (Physician, Academic Health Center)
However, there is a tension for change among participants, specifically clinicians, if this requires EHR alerts to view SNS results.
“There are so many stops and clicks and breaks. It’s just alert fatigue. So, I would be really hesitant to put in another, stop what you’re doing, do this. I want to be able to access this information in the time and the order that I want to do it.” Participant 11 (Physician, Academic Health Center)
Referrals phase
Theme 6: A major barrier to SNS integration is a lack of targeted responses related to referrals
Health care professionals are not willing to screen patients for social needs if there is no strong network of resources available. One participant expressed that SNS need to be used not just for creating care plans, but also to have strategies and protocols in place to address the needs.
“I think a standardized tool would be helpful, with…three caveats. Can we implement it into the workflow? Do we have the resource to do that?…Do we have an evidence base for the implementation of the social needs screener?…And then…what is the plan for follow-up?” Participant 1 (Physician, Academic Health Center)
Theme 7: Creating a “closed loop” and stronger follow-up efforts reinforces the need for SNS
Another barrier that all participants reported is not knowing when social needs are being met.
“I don’t know how much follow-up there is afterwards other than when the client were to come back to the office or call the office.” Participant 6 (Nurse, Federally Qualified Health Center)
Clinicians, after referring patients to social workers, report not knowing the outcome of the referral unless the patient comes in for another visit soon after the referral. Participants specifically wish to “close the loop” and ensure that patients’ social needs are being met.
“A lot of times, with housing, I will definitely stay in the loop to ensure that the person actually gets moved in. I will do some follow-up with the person, and sometimes, depending on the agency that is working with them as well, we do some collaborating to ensure that they’re staying successful within that housing arrangement.” Participant 9 (Social Worker, Federally Qualified Health Center)
According to social services or support staff, follow-up efforts need to be streamlined.
“You’d want to close the loop, see this play out and hopefully in a good way.” Participant 5 (Physician, Academic Health Center)
Efforts to streamline follow-up would include understanding if the referral was effective in addressing the screened social need.
“We do continue to follow-up with them and so either they have met their goals, they stop answering us, or they just say, I think I’ve got it from here. I don’t really need your help anymore.” Participant 3 (Social Worker, Federally Qualified Health Center)
For patients whose needs are not met, participants want to have the opportunity to strategize other solutions.
“And then there needs to be checkpoints of like, okay, we talked about this in the beginning. We’ve made these referrals, so talk to me then about what has worked for you, what hasn’t worked for you, and how do we shift and move around to meet your needs. So, there has to be these checkpoints throughout the process and time is always a barrier.” Participant 2 (Social Worker, Academic Health Center)
Efforts to ensure that the referral to social work was effective requires formal and informal communication and relational connection between social workers and community resources. This relationship connection extends beyond social workers and community resources; it includes the relationship between social workers and clinicians. Variability exists in these relationships. In FQHCs, there is a “culture” of using a comprehensive patient-centered approach where clinicians and social workers are in contact consistently.
“We have a pretty good system of being able to collaborate, send our notes directly to providers whenever needed.” Participant 6 (Social Worker, Federally Qualified Health Center)
Participants from the academic health system reported that contact is often lost. Providers are told if contact was attempted or made between the social worker and the patient, but little information is shared about the outcomes.
“We often don’t know the outcome, maybe in a timely manner or not at all. Sometimes it takes time until the next follow-up visit with the patient.” Participant 8 (Physician, Academic Health Center)
Theme 8: Outreach is the key to developing a strong network for resources
In the referral phase, social workers are essential in the process of identifying resources through their community outreach.
“With such limited resources, you really have to build rapport and connection … But just making sure that those connections stay intact, doing the events, going out, and being part of educational events.” Participant 9 (Social Worker, Federally Qualified Health Center)
There is a noted barrier where there is not enough supply to meet the demands.
“I would want more resources. You mentioned a community health worker. We don’t really have access to any. That would be really helpful. And there may be other resources too that could be helpful for our patients besides the social worker.” Participant 8 (Physician, Academic Health Center)
Lack of resources in the area leads to difficulty connecting patients to resources. Many participants understand that this barrier can only be rectified though policy.
“But I think systematically, there’s a lot of gaps and it’s not to any fault of specific organizations or anything. It’s just funding and availability.” Participant 10 (Social Worker, Federally Qualified Health Center)
Medical-legal partnership phase
Theme 9: MLPs are overwhelmingly seen as a helpful resource
All participants agree that MLPs would be helpful to address patients’ social needs but very few had experience with MLPs in their primary care. Of those that did, the experience was limited and MLPs have not been integrated into any of the workflows observed.
“I think that it is very beneficial. I think that they [MLPs] have that expertise, especially for undocumented individuals” Participant 2 (Social Worker, Academic Health Center)
Despite the perceived support of MLPs, participants agree that defining the nature of the relationship is the cornerstone for integrating legal intervention as a resource.
“I think I like the idea of a partnership. But I think that partnership is really– for the partnership to be useful, we really need to understand what each other does” Participant 1 (Physician, Academic Health Center)
Theme 10: Cross-disciplinary education is essential to support a successful relationship between MLPs and primary care
Participants agree that primary care teams need to be educated on the intricacies of MLPs, the limitations of legal intervention, and how legal representation operates.
“They could help educate us about processes, especially in the state with respect to how housing issues are handled or problems related to medical assistance” Participant 8 (Physician, Academic Health Center)
By the same principle, participants assert that legal representatives need to be educated on how clinical spaces operate and the barriers clinicians have relative to identifying issues like medical necessity.
“If we were to work with attorneys, it would be extremely important that they understand how to actually be helpful, not just to the patient, because that’s obviously, that’s really important, but to understand how we work and what we need from the patient to do this extensive documentation.” Participant 1 (Physician, Academic Health Center)
Finally, educating patients about MLPs can increase their willingness to seek out legal representation. An example of education could include discussing the ability of the patient to dictate what amount of access they want the MLPs to have for their EHR.
“So, I’m trying to think of any reason that they would not need access to everything in the medical record. Nothing comes to mind honestly. So, I’d say unfettered access would be my expectation.” Participant 11 (Physician, Academic Health Center)
Theme 11: The physical presence of MLPs in primary care is up for debate
When asked how integrated MLPs should be into the clinical space, participants differ with some agreeing that MLP representatives can be integrated and almost serve as an in-house resource.
“I walk out the door and down the hall. I tuck on someone’s sleeve and then they pop into the room and help take care of it. I think would be the ideal. They’re ready and available immediately and we have enough rooms for them to be able to spend 20 minutes in the room with the patient and it doesn’t jam up the works.” Participant 11 (Physician, Academic Health Center)
One participant believes that MLPs having a physical presence in the facility will increase patient comfort discussing their social or legal needs.
“By showing up in the clinic and being a face or just talking to them, it’s going to make those who screen feel a little bit more comfortable, because a lot of times and even when we’re finding out when some have screened positive, they don’t want to talk to anyone.” Participant 4 (Education Program Specialist, Academic Health Center)
Social workers and non-clinical staff are more likely to want MLPs to be in-house. Those who were hesitant to ingratiate MLPs want to first ensure that there is enough supply to meet the demand. Clinicians, on the other hand, believe MLPs can serve as a resource like any other social service organization.
“I almost think about it like a consult or that they have, here are the things they need to move, advance the work that they’re doing and we would supply that.” Participant 5 (Physician, Academic Health Center)
Discussion
This study aimed to identify the barriers of and facilitators to SNS and MLP integration in primary care facilities. From the themes identified, increasing SNS adoption in these facilities is possible by incorporating the feedback of primary care teams. Implementation strategies, to that end, recommend establishing and using advisory boards and workgroups [Reference Powell, Waltz and Chinman30]. Because the patient-provider interaction is reportedly unavailable for intervention based on the interviews in this research, focus should turn to training other members of the clinical staff. Proper training should include didactic and experiential learning. Didactic sessions should educate clinical staff about the importance of SNS and the process of screening. This finding is further supported by a qualitative study on MLP integration into primary care, where having “buy-in and a clinical champion improved communication and strengthened coordination” [Reference Liaw, Bakos-Block and Northrup31]. Representatives from referral resources would facilitate the experiential learning component. Facilitating the clinical staff members to gain knowledge and hands-on experience with the referrals themselves would increase their ability to accurately refer patients to resources [Reference Massar, Berry and Paul32].
The present study also found barriers and facilitators to the use of MLPs as a referral resource, despite MLPs being seen as overwhelmingly helpful. Clinic staff members, irrespective of their role or the type of primary care setting they work in, agree that legal representation can improve patients’ social needs. Using this information, future studies should identify early adopters of MLPs who could serve as champions to encourage other colleagues and facilities to collaborate with MLPs. Related to education, rather than educating and training primary care teams in the ways of using MLPs and referring patients to this resource, the emphasis of future studies should be on the development and delivery of a cross-disciplinary curriculum. It is also important that the clinical staff and MLP representatives understand the roles and capacities of either discipline.
Another barrier identified relates to physical structure. Physical presence can increase MLP engagement with patients [Reference Mantel and Fowler33]. Participants in this study differed in their opinions regarding the physical presence of MLPs in the clinical facility. More research should be conducted as to why this barrier exists and testing whether providers are more comfortable making the MLP referral when physical presence exists. For the clinical spaces that are willing to have MLPs ingrained into the physical space, efforts must be made to ensure privacy for patients to speak freely and preserve attorney-client confidentiality.
Our study also identified three contextual factors that need to be considered to facilitate SNS use. The first involves EHR systems. Based on the results, clinicians want to have SNS data to be readily accessible in their respective EHR systems. This, however, is based on whether the record systems have the infrastructure necessary to facilitate the input of SNS data. The second factor involves the screener tools themselves. There are limitations to the more popular, validated tools. More work needs to be done to offer the screeners in multiple languages like the PRAPARE tool [Reference Hernandez, Khoong and Kanwar34]. Additionally, infrastructure should be available to easily translate screeners for English-speaking health care professionals. Another way that literature shows SNS completion can increase is based on offering an abbreviated screener questionnaire [Reference Peahl, Rubin-Miller and Paterson35]. To increase SNS generally, using short-form screeners may improve intake while not overwhelming clinical workflows. However, research needs to be done on developing these tools and implementing them into primary care facilities. The third consideration revolves around the lack of supply to meet the demand associated with SNS referrals. There are not enough community resources to meet the needs of patients. Issues related to funding and human capacity can serve as a hinderance to access to referral resources [Reference Kazi, Starling and Milicia36]. Research suggests that data from SNS can be used to advocate for the apparent need for resources to address social needs identified by the screener [Reference Painter, Parry, McCann, Dehn Lunn and Ford1]. On the other end of this issue is the importance of referral pathways. Many clinicians are unaware of the resources available [Reference Lian, Kutzer and Gautam15,Reference Rodriguez, Ravi, Thompson and Ferrer37]. By creating strong partnerships between community resources and primary care facilities, clinicians will be more knowledgeable and able to connect patients more effectively [Reference Rodriguez, Ravi, Thompson and Ferrer37]. Overall, future studies may need to factor in how these contextual factors can impact the use of screening and referrals. More than that, future policy efforts should focus on expanding funding of social service programs and non-profit organizations.
There are several strengths and limitations of this study. In terms of strengths, all participants worked at different sites, within three large health care systems, bringing the unique perspectives from eleven primary care facilities with different clinic workflows. Additionally, the use of process mapping methodology fostered systems-focused responses from participants and allowing them to visualize their responses during the interviews. In using a process mapping methodology, a limitation should be noted. The development of the process map, while informed by the experiences of health care professionals in primary and specialty care, was based on the workflow of a single hospital system. Perspectives from other types of primary care systems, like FQHCs, were not included. Regarding study limitations, although saturation was reached with only eleven interviews, participants were from the same geographic area of Central Pennsylvania, limiting the generalizability of study fundings beyond this region. Second, the sample size was only 11 participants, each from different primary care sites. The ways these providers engage with patients vary. Further, because most of the participants are either social workers or physicians, there are many providers in primary care who are missing from the analysis. Third, there is another generalizability limitation because most participants worked in family medicine. Additionally, the clinician participants exclusively worked in academic health centers and almost all the social worker participants worked in FQHC. Finally, it is likely that some participants were not fully aware of their SNS processes, providing an incomplete perspective of their clinic workflow for the topic under study. Future research into implementation of SNS and MLPs into the patient workflow should involve perspectives from health care professionals and patients to better strategize tailored solutions for SNS integration.
Author contributions
Jamelia D. Graham: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing-original draft; Jen L. Kraschnewski: Resources, Writing-review & editing; Sophia Allen: Writing-review & editing; Medha Makhlouf: Writing-review & editing; Nehath Sheriff: Formal analysis, Investigation; Josheili Llavona-Ortiz: Investigation; William A. Calo: Conceptualization, Methodology, Supervision, Writing-review & editing.
Funding statement
Jamelia Graham received a Translational Science Fellowship award supported by the National Center for Advancing Translational Sciences, grant U54 TR002014-05A1. The content is solely the responsability of the authors and does not necessarily represent the official views of the NIH.
Competing interests
There are no conflicts of interest among any of the authors.
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