Utilizing a Tailored Approach to Standardized Screening of Health-Related Social Needs

Despite the increased awareness of social determinants of health (SDoH), integrating social needs screening into healthcare practice has not consistently occurred. The purpose of this quality improvement project was to implement a social needs screening tool and referral process tailored to clinical workflow in a hemodialysis clinic in order to increase social needs identification and referrals to community resources. The Model for Improvement was used to implement the Core 5 social needs screening tool, a staff referral process, and a staff evaluation of the tool and process among the nursing staff. Overall, 21 (28%) of 73 dialysis patients screened had 32 additional unmet social needs identified using the Core 5 tool. The 32 social needs were reported to the social worker using the referral process and received referrals to community resources. The staff nurses demonstrated high acceptance and usability of the Core 5 tool and process, with a 4.8 (out of 5) score. Implementing a standardized screening and referral process customized to clinical workflow enhanced the identification of social needs in patients undergoing hemodialysis, thus improving the healthcare team’s ability to address potential SDoH.