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10.1017/cts.2023.652
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Learning in Real World Practice: Identifying Implementation Strategies to Integrate
Health-Related Social Needs Screening within a Large Health System
Kevin Fiori1,2,4, Samantha Levano1, Jessica Haughton1, Renee Whiskey1, Andrew Telzak1, Sybil
Hodgson1,3, Elizabeth Spurrell-Huss4, Allison Stark1,5
1Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, New
York, USA
2Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
3Montefiore Medical Group, Bronx, NY, USA
4Office of Community & Population Health, Montefiore Health System, Bronx, New York, USA
5Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
Keywords: social determinants of health, health-related social needs, health equity, learning
health system, quality improvement
Corresponding Author: Kevin Fiori, kfiori@montefiore.org, 917-331-1223, 1300 Morris Park
Avenue, Bronx, NY 10461
Disclosures: The authors have no conflicts of interest to disclose.
https://doi.org/10.1017/cts.2023.652 Published online by Cambridge University Press
Abstract
Introduction: Health systems have many incentives to screen patients for health-related social
needs (HRSNs) due to growing evidence that social determinants of health (SDoH) impact
outcomes and a new regulatory context that requires health equity measures. This study describes
the experience of one large urban health system in scaling HRSN screening by implementing
improvement strategies over five years, from 2018 to 2023.
Methods: In 2018, the health system adapted a 10-item HRSN screening tool from a widely
used, validated instrument. Implementation strategies aimed to foster screening were
retrospectively reviewed and categorized according to the Expert Recommendations for
Implementing Change (ERIC) study. Statistical process control (SPC) methods were utilized to
determine whether implementation strategies contributed improvements in HRSN screening
activities.
Results: There were 280,757 HRSN screens administered across 311 clinical teams in the health
system between April 2018 and March 2023. Implementation strategies linked to increased
screening included integrating screening within an online patient portal (ERIC strategy: involve
patients/consumers and family members), expansion to discrete clinical teams (ERIC strategy:
change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical
data to providers), and deploying Community Health Workers (CHWs) to address HRSNs (ERIC
strategy: create new clinical teams).
Conclusions: Implementation strategies designed to promote efficiency, foster universal
screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool
appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening
demonstrate the cumulative effects of implementation strategies and the health system’s
commitment towards universal screening.
https://doi.org/10.1017/cts.2023.652 Published online by Cambridge University Press
Introduction
Health systems have clear interest and new incentives to focus on patients’ social determinants of
health (SDoH) due to growing evidence that reducing inequities in health outcomes depends on
addressing an individual’s social needs [1]. The World Health Organization (WHO) defines
SDoH as “the conditions, in which people are born, grow, work, live, and age, and the wider set
of forces and systems shaping the conditions of daily life” [2]. These determinants drive inequity
in health outcomes through the insidious effects of poverty and racism manifested through
health-related social needs (HRSNs) such as limited access to nutritious foods, unemployment,
and unstable, unaffordable, or low-quality housing [1]. According to the WHO Conceptual
Framework for Action on the Social Determinants of Health, a health system is uniquely
positioned to mitigate the effects of HRSNs by increasing access to and promoting integration of
social care services.
Evidence has shown that unmet HRSNs contribute to poor health outcomes through increased
exposure to risk factors for chronic conditions, higher likelihood of chronic stress, and decreased
access to resources for those with pre-existing conditions [3]. Patients with HRSNs also have
higher emergency department utilization [4-6], higher hospital admissions [7 8], higher rates of
hospital readmission [9], and higher rates of missed ambulatory appointments [10 11], which
coincide with higher cost to the health system [12]. Recent interventions integrating social care
in clinical settings have demonstrated improvements in health outcomes and cost by addressing
food security [13], housing stability [14 15], and legal assistance [16 17].
In addition to health system factors driving HRSN screening, the regulatory context has shifted
with the release of new health equity measures from the Centers for Medicare & Medicaid
Services (CMS) [18], the Joint Commission [19], and the National Committee for Quality
Assurance [20]. The National Academies of Sciences, Engineering, and Medicine (NASEM) also
recently provided health system guidance on HRSNs through the identification of five
complementary activities, namely Awareness, Adjustment, Assistance, Alignment, and
Advocacy, recommended to facilitate social care integration [21]. Awareness activities are
intended to identify HRSNs and community assets; Adjustment aims to change the approach to
clinical care to accommodate HRSNs; Assistance reduces the burden of HRSNs through social
service navigation; Alignment invests in and facilitates the organizing of existing community
https://doi.org/10.1017/cts.2023.652 Published online by Cambridge University Press
assets to address HRSNs; and Advocacy promotes policies that facilitate the creation or
redeployment of resources to address HRSN. Although this cascade of social care integration
activities relies on efforts to increase Awareness of HRSNs, there are many practical challenges
related to health systems’ ability to scale Awareness activities. This study describes the
experience of one large urban health system in scaling HRSN Awareness efforts through
screening and implementing improvement strategies over five years, from 2018 to 2023.
Materials & Methods
Setting
In 2017, a multidisciplinary team of administrators, clinicians, social workers, and community-
based partners was formed to develop a system-wide strategy to implement HRSN screening
across a network of ambulatory and inpatient practices within a large, urban health system in
Bronx County, New York [22]. The HRSN screening tool was initially tested for feasibility and
acceptability at selected practices prior to its full-scale integration within the electronic health
record (EHR) in April 2018. The standardized screening tool was adapted from a widely used,
validated instrument, the Health Leads screening toolkit [23]. The final tool was launched across
the health system, including inpatient, ambulatory primary care, and specialty practices, and
included 10 HRSN categories: housing security, housing quality, food security, utilities, health
transportation, medications, child or elderly care, legal services, family stress, and safety. The
tool was designed to be patient self-administered and distributed during routine clinical visits in
the nine most common languages in the catchment area. Data entry into the EHR was facilitated
by standardized workflows that included both administrative and nursing staff members.
The screening tool was available to all clinical practices in the health system through EHR
integration. Each practice had the discretion to select which patients should be screened and at
what frequency based on patient volume and staff availability, given the lack of evidence-based
guidelines. There was also variability in resources available at each practice with some clinical
teams having full or part time socials workers or Community Health Workers (CHWs) to
connect patients to essential social services, while others relied on resource lists generated from
available social service resource directories. All practices, however, adhered to the core
components of the intervention, which included using the standardized screening tool, providing
patients with resources if a need was identified and assistance was requested, and data entry in
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the EHR interface prior to the clinician visit. The study was reviewed and approved by the Albert
Einstein College of Medicine institutional review board (2017-8434).
Deliberate Implementation Strategies
We retrospectively reviewed implementation strategies utilized during the study period with key
stakeholders and categorized each strategy according to the Expert Recommendations for
Implementing Change (ERIC) implementation strategy taxonomy [24]. The ERIC taxonomy
provides a uniform language for implementation strategies across contexts and clarity for
separate and concrete actions. Use of a common language for implementation strategies in
clinical and translational research supports efforts to implement and scale programs to other
contexts. We selected the ERIC taxonomy for this study because of its fit in the healthcare
context and recognition in the field [25 26].
The implementation strategies employed were deliberate attempts to increase the volume of
HRSN screens administered within specific clinical teams and, more broadly, systematically
across the health system. We did not consider events external to the health system (i.e., public
health emergencies, state or national policy changes) in this analysis because, although they may
have impacted screening, these events were not implemented as part of ongoing scale or quality
improvement processes.
Implementation strategies included: (1) developing a novel role in the health system and
appointing the first Director of SDoH to coordinate and support screening (January 2020), (2)
creating an Executive Working Group consisting of key health system leaders (February 2021),
(3) launching a Clinician Champion Working Group to foster a collaborative learning
environment and support clinical teams that are directly implementing the intervention (April
2021), (4) disseminating a Screening and Referral Toolkit to provide centralized guidance and
resources to assist clinical teams with effectively implementing the screening initiative (May
2021), (5) integrating the screening tool within the EHR supported online patient portal (June
2021), (6) expanding implementation to discrete clinical teams with leadership support (March
2022), (7) providing data feedback loops to track process measures with clinician champions and
other stakeholders (September 2022), and (8) deploying CHWs to address HRSNs identified
through screening and connect patients to social services (September 2022).
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In most cases, implementation strategies were defined and planned several months prior to the
described date of implementation. This pre-implementation process included changes in
infrastructure, information technology development, networking and meeting with key
stakeholders, and staff training. We reported a one-month time window (i.e., date of
implementation) for each implementation strategy to represent the date when the strategy was
first deployed or launched within the health system (e.g., first meeting for Executive Working
Group, first time the Screening and Referral Toolkit was shared with clinician champions, first
time screening was administered in the online patient portal).
There is a well-defined lag between health research evidence generation and translation into
clinical practice [27], however the potential lag between implementation and effect is less clear
in quality improvement processes. We hypothesized that many of our implementation strategies
(#1-4 and #7-8) would have lagged (or potentially combined) effects on HRSN screening due to
their reliance on behavior change, which includes adopting new roles, influencing other
clinicians to screen for HRSNs, and utilizing toolkits and data feedback loops. Meanwhile, the
date of implementation for strategies #5 and #6 reflects the date of effectuation due to
prospective data review and validation in the EHR during the implementation period (Figure 1,
Figure 2).
Statistical Analysis
Measures related to the number of HRSN screens completed were extracted from the EHR using
Microsoft SQL Server, version 18, to query data from the Epic Electronic Health Record Data
Warehouse. The primary outcome of interest was the number of HRSN screens completed per
month, which included data from patients screened multiple times across the study period.
We utilized statistical process control (SPC) methods to assess whether our implementation
strategies contributed special causes of variation over the first five years of the intervention [28
29]. The Individual and Moving Range (I-MR) Chart was selected to visualize the aggregate
number of screens administered per month as well the moving range, or the difference in screens
between the current month and the previous month. The primary assumption of SPC is that all
processes are subject to variation (i.e., common cause variation), which represents the random
distribution of observations around the central tendency due to chance and inherent to the
process.
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All observations between the lower (LCL) and upper control limits (UCL), which are 3 sigma
below (μ – 3 σ) and above the mean (μ + 3 σ) number of screens administered per month,
respectively, were reported as common causes of variation [28]. Meanwhile, observations
outside the LCL and UCL were defined as special cause variation. In addition to special cause
variation, we also identified trends, defined as six consecutive points increasing or decreasing, in
the number of screens administered over time. Measures in the I-MR Chart followed a normal
distribution and were calculated using the SHEWHART procedure in SAS version 9.4 [30].
Results
Study Sample
There were 280,757 total HRSN screens successfully administered across 311 distinct clinical
teams in the health system during the first five years of implementation between April 2018 and
March 2023. This represents an acceptance rate of 91.7%, with an additional 25,383 screens
declined among 18,336 unique patients. Of the patients who declined a screen, 7,908 were
excluded in the study sample and 10,428 were included for a screen accepted during another
clinical encounter in the study period. The study sample includes data from 171,896 unique
patients, of which 59,914 (34.9%) were successfully screened multiple times.
The HRSN screening tool was primarily administered in outpatient settings (91.6%) with few
screens completed in inpatient and emergency settings (8.4%). There were 101,738 (39.6%)
screens administered in outpatient internal medicine, 83,935 (32.6%) in pediatrics, 40,307
(15.7%) in family medicine, 14,939 (5.8%) in obstetrics/gynecology, 10,795 (4.2%) in the care
management organization, 1,275 (0.5%) in cancer care, and 4,168 (1.6%) screens administered in
other outpatient programs.
Additional descriptive statistics are included to better understand the reach of implementation but
limited to outpatient practices with documented HRSN screens during the study period. Between
April 2018 and March 2023, the HRSN screening tool was administered at 5.1% (n=257,157) of
clinical encounters (N=5,075,308) in outpatient practices of interest. Meanwhile, 25.7%
(n=154,651) of active patients (N=602,780) were screened for HRSNs. In the first year of
implementation, 39,377 screens (3.9% of 1,012,094 encounters) were administered to 34,003
unique patients (10.2% of 334,278 active patients) across 90 clinical teams (Figure 3). By the
https://doi.org/10.1017/cts.2023.652 Published online by Cambridge University Press
fifth year, 93,877 screens (9.1% of 1,033,860 encounters) were administered to 80,527 unique
patients (25.4% of 316,431 active patients) across 223 clinical teams.
Of the total 171,896 unique patients screened, most were between 30 and 64 years of age
(40.9%), female (62.0%), Hispanic (39.2%) or non-Hispanic Black (29.2%), preferred English as
their primary language (82.1%), and enrolled in Medicaid (39.8%) or commercial insurance
(32.8%), according to their most recent screen (Table 1). High HRSN screening completion rates
for female patients reflect the higher distribution of females in the active outpatient population
(59.6%) as well as utilization of the screening tool in obstetrics/gynecology practices (5.8% of
screens). There were 26,193 patients (15.2%) who reported at least one HRSN, with food
security (4.9%), housing quality (4.6%), housing security (4.0%), and healthcare transportation
(3.6%) identified as the most frequently reported HRSNs (Table 2).
Implementation Strategies & Statistical Process Control
Figure 4 presents I and MR Charts of screening data over time overlayed with retrospectively
reviewed implementation strategies linked to abnormal or special cause variation. In the first five
years of implementation, 35 of the 60 months (58.3%) signaled abnormal variation (Figure 4).
Special cause variation in the I Chart (below the LCL=3,011.75) was first detected in November
2019, December 2019, and December 2020; however, these observations did not coincide with
known changes to implementation strategies (Table 3).
Between March 2020 and October 2020, we observed special cause variation (below
LCL=3,011.75) coinciding with the start of the COVID-19 pandemic. Between April 2020 and
September 2020, we also witnessed a positive trend (i.e., six consecutive points increasing) in
screening, which indicates the return to baseline prior to COVID-19. Special cause variation
below the LCL was also observed in January 2021 and February 2021 coinciding with the rapid
emergence of the SARS-CoV-2 B.1.526 variant in New York City (NYC) [31].
The I chart first suggested special cause variation above the UCL (UCL=6,346.82) between June
2021 and November 2021 followed by another period of sustained variation between March
2022 and March 2023. Special cause variation identified in June 2021 coincided with the
integration of the HRSN screening tool into the EHR’s online patient portal (Figure 1). This
special cause variation (above UCL=6,346.82) was sustained through November 2021.
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The second period of special cause variation above the UCL in the I chart aligned with the
systematic launch of the intervention across all ambulatory practices within one clinical
department in March 2022 (Figure 2). Although special cause variation was sustained above the
UCL through March 2023, there appears to be an increase in screening between July and August
2022. This is likely due to the anticipation of CHWs deployed in September 2022, which
required clinical teams to screen patients before completing referrals to address unmet HRSNs.
The deployment of CHWs was implemented alongside the launch of data feedback loops, which
were focused on implementation outcomes and measures tracking successful connection to social
services. These strategies likely contributed cumulative effects on HRSN screening volume over
the remainder of the study period.
The MR chart detected two timepoints with special cause variation above the UCL
(UCL=2,048.78), first in June 2021 and then in March 2022, which support the previously
described associations between screening and integration into the online patient portal and
expansion to clinical teams, respectively. These implementation strategies yielded the greatest
impact on screening.
Discussion
We determined that scaling HRSN screening within a large health system over time is feasible
and can be accelerated through targeted strategies that foster screening activities. In our health
system, the volume of HRSN screening increased nearly three-fold from year one to year five of
implementation. We observed multiple implementation strategies that seemed to influence
screening including the deployment of CHWs to connect patient with HRSNs to social services
and the provision of data feedback loops to track key process measures; however, the integration
of the screening tool into the EHR’s online patient portal and deliberate expansion within a
clinical department yielded the largest observed increases in HRSN screening. The sustained
increase in screening observed over the last two years of implementation, even in the wake of
COVID-19, was likely due to the cumulative effects of the implementation strategies cited and
the health system’s continued commitment to improving screening.
Several studies have evaluated facilitators and barriers to screening for HRSNs in clinical
settings; however, the most relevant to our study is that from the NYC Health + Hospitals (H+H)
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SDoH screening and referral program [32]. The challenges identified by NYC H+H include
integration of screening into clinical workflows, burden on staff, limitations within patient
population (e.g., health literacy, English proficiency, immigration status, screening fatigue) and
capacity for data entry. NYC H+H also defined best strategies utilized in their intervention
including the unique adaptation of the screening tool for each practice, integration of screening
into existing workflows, promotion of universal screening, development of referral resources,
utilization of technology and data systems, and allocation of dedicated staff for the intervention.
Most of the previously described best practices align with implementation strategies applied in
our intervention except for the adaptation of the screening tool, which is standardized across our
health system.
Although NYC H+H integrated the HRSN screening tool into the EHR, there was no mention of
its administration in the health system’s online patient portal. In our study, we hypothesize that
integrating the screening tool into the patient portal expanded the reach of the intervention by
automating the screening process for patients enrolled with an upcoming clinical visit. Several
studies have reported staff concerns with time needed to complete HRSN screeners [33-35].
Clinical teams within our health system have expressed that integration into the patient portal has
reduced the additional burden on staff, who were previously solely responsible for administering
screens and documenting patient responses. The automation of HRSN screening in patient
portals has demonstrated success in other studies [36 37] with some patients reporting a greater
likelihood to endorse HRSNs in asynchronous modalities [38]. This strategy, however, has also
been identified as a barrier in clinical practices where enrollment is low [39].
Integrating the screening tool into the patient portal increases patient engagement with
implementation, but there remains a demonstrated need to improve clinician motivation to screen
and capacity to act on HRSNs identified. Clinicians have previously reported both a lack of
training on HRSNs and lack of resources to address HRSNs as key barriers to screening [34 40-
42], with some arguing that screening for HRSNs without linking patients to resources is
ineffective and unethical [43]. In addition to clinicians, patients have also expressed the
importance of clarifying the purpose of the HRSN screen, especially if to connect patients to
social services [38 42]. CHWs have been proven to be an effective way to address HRSNs in
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several studies, including within our health system [44]. Addressing HRSNs through CHWs and
facilitating the relay of CHW referral data can increase screening behavior among clinical teams.
Expansion of HRSN screening to targeted, new clinical teams across the health system is another
key facilitator to screening interventions [32 45]. Our health system recommends but does not
mandate universal screening for HRSNs; therefore, as seen in our analysis, continuing to expand
implementation to discrete clinical practices is critical to increase the reach of the intervention.
Although all clinical teams have access to the screening tool in the EHR, aligning around a
universal health system target to foster accountability at each practice and specialty may further
advance screening.
Limitations
There are several limitations to address in this study. First, we retrospectively reviewed
implementation strategies and their dates of implementation, which were selected based on staff
recall and available documentation. This may introduce both recall and selection bias, as
strategies were selected by stakeholders based on their perceived significance. We also linked
implementation strategies in this study to changes in HRSN screening rates within a one-month
period (within the defined ‘implementation window’). This limits our ability to determine the
lagged and combined effects of implementation strategies over time. It may also explain the
observed significance of implementation strategies with hypothesized immediate effect, while
undervaluing the effects of implementation strategies which may be lagged, or those that whose
effects were most pronounced in combination with other strategies. There is limited evidence on
the lag time required for clinicians and stakeholders to change their behaviors, which overall
limits our interpretation of the results [46].
We only selected implementation strategies utilized at the system level not the clinical team
level; therefore, we cannot conclude whether special cause variation was signaled from only one
or a subset of clinical teams. We also cannot account for all external events that may have
impacted screening in this analysis. Regarding COVID-19, we could not connect screening data
with surges within the health system specifically, only across the Bronx and NYC.
For both implementation strategies and external events, we cannot assume causality for
variations and trends in screening identified through SPC methods. Additionally, since SPC
methods were not initially developed for health research, the control chart cannot account for
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provider or patient-level variability in screening behavior. In the SPC analysis, we also did not
account for the difference in the number of active patients or completed clinical visits per month.
There are potential autocorrelation issues given the cumulative effects of implementation
strategies on performance improvement, with previous increases in screening predicting future
increases in screening.
Another potential limitation of this study is that the sample of patients screened may not be
representative of all active patients in the health system. Clinical teams had the discretion to
screen subsets of their patient population, with some only screening new patients, patients with
scheduled annual visits, or patients assumed to have HRSNs. While we are unable to define if the
subset of screened patients are categorically different from those that have gone unscreened, we
can say that the demographic characteristics of screened patients matches those of the overall
health system.
Conclusions
Integrating a learning health system approach that identifies strategies that foster HRSN
screening uptake offers a path forward to promoting health equity activities. We found that
implementation strategies designed to promote efficiency, foster universal screening, link
patients to resources, and provide clinical teams with an easy-to-integrate tool seem to have the
greatest impact on the yield of completed HRSN screeners. More rigorous research, including
mixed methods studies, are still needed to advance practice-based evidence that will promote
health equity within our health systems and integrate comprehensive clinical and social care for
our patients.
Acknowledgments: The authors are grateful to those from Montefiore Medical Group who
helped develop and implement the screening tool.
Funding: This work was supported by the Doris Duke Charitable Foundation (grant 2018169).
The content is solely the responsibility of the authors and does not necessarily represent the
official views of the funders.
Disclosures: The authors have no conflicts of interest to disclose.
https://doi.org/10.1017/cts.2023.652 Published online by Cambridge University Press
Table 1. Descriptive Characteristics of Unique Patients Screened for Health-Related Social Needs
within a Large Urban Health System, 2018-2023
N (%)
Total Unique Patients Screened
171,896 (100.0%)
Age at Most Recent Screening
0-5
17,464 (10.2%)
6-11
15,183 (8.8%)
12-19
16,857 (9.8%)
20-24
9,269 (5.4%)
25-29
9,214 (5.4%)
30-64
70,377 (40.9%)
65+
33,532 (19.5%)
Sex
Male
65,354 (38.0%)
Female
106,521 (62.0%)
Unknown
21 (0.01%)
Race and Ethnicity
Non-Hispanic White
17,784 (10.4%)
Hispanic
67,357 (39.2%)
Non-Hispanic Black
50,142 (29.2%)
Non-Hispanic Asian / Pacific Islander
4,518 (2.6%)
Non-Hispanic American Indian / Alaskan Native
684 (0.4%)
Other
13,850 (8.1%)
Declined to Report or Not Available
17,561 (10.2%)
Preferred Language
English
141,129 (82.1%)
Spanish
25,118 (14.6%)
Other
3,999 (2.3%)
Declined to Report or Not Available
1,650 (1.0%)
Insurance Status
Commercial
56,380 (32.8%)
Medicaid
68,416 (39.8%)
Medicare
29,655 (17.3%)
Other
7,107 (4.1%)
Uninsured
10,338 (6.0%)
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Table 2. Health-Related Social Need Status of Unique Patients Screened within a Large Urban
Health System, 2018-2023
N (%)
Total Unique Patients Screened
171,896 (100.0%)
Yes, n (%)
No/Declined to Report, n (%)
At Least 1 HSRN at Most Recent
Screening
26,193 (15.2%)
145,703 (84.76%)
Housing Security
6,922 (4.1%)
164,974 (95.97%)
Housing Quality
7,932 (4.6%)
163,964 (95.39%)
Food Security
8,395 (4.9%)
167,081 (97.20%)
Utilities
4,815 (2.8%)
163,501 (95.12%)
Health Transportation
6,191 (3.6%)
165,705 (96.40%)
Medications
5,166 (3.0%)
166,730 (96.99%)
Child or Elderly Care
3,905 (2.3%)
167,991 (97.73%)
Legal Services
4,135 (2.4%)
167,761 (97.59%)
Family Stress
3,891 (2.3%)
168,005 (97.74%)
Safety
1,240 (0.7%)
170,656 (99.28%)
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Table 3. Deliberate Implementation Strategies & Expert Recommendations for
Implementing Change (ERIC) Categories [24]
Deliberate
Implementation
Strategy
Description of
Deliberate
Implementation
Strategy
ERIC
Implementation
Strategy
ERIC Implementation
Strategy Definition
1: Appointed
“Director of Social
Determinants of
Health” in the
health system
(January 2020)
Created a new
leadership position to
facilitate uptake of
social needs screening
across the health system
Mandate change
Have leadership declare
the priority of the
intervention and their
determination to have it
implemented
2: Launched
Executive Working
Group for HRSN
screening
(February 2021)
Developed working
group with key
members of health
system leadership and
influential colleagues
and organized monthly
meetings to inform
implementation and
influence colleagues to
adopt screening
initiative
Involve executive
boards
Involve existing governing
structures (e.g., boards of
directors, medical staff
boards of governance) in
the implementation effort,
including the review of
data on implementation
processes
3: Launched
Clinician
Champion
Working Group for
HRSN screening
(April 2021)
Developed working
group with clinicians
who are implementing
the screening initiative
and organized monthly
meetings to foster a
collaborative learning
environment to share
barriers and facilitators
to implementation
Organize clinician
implementation
team meetings
Develop and support teams
of clinicians who are
implementing the
innovation and give them
protected time to reflect on
the implementation effort,
share lessons learned, and
support one another’s
learning
4: Developed &
Disseminated
HRSN Screening
and Referral
Toolkit to clinical
partners (May
2021)
Developed and
distributed a toolkit to
provide centralized
guidance and resources
to assist clinical
practices with
effectively
Develop &
distribute
educational
materials
Develop and distribute
manuals, toolkits, and
other supporting materials
in ways that make it easier
for stakeholders to learn
about the innovation and
for clinicians to learn how
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implementing the
screening initiative
to deliver the clinical
innovation
5: Integrated
HRSN screening
tool into the EHR
supported online
patient portal (June
2021)
Launched HRSN
screener in new
platform, the online
patient portal, which
allowed patients to self-
administer the screen
online prior to their
scheduled clinical
appointment
Involve
patients/consumers
and family
members
Engage or include
patients/consumers and
families in the
implementation effort
6: Expanded social
needs screening to
discrete clinical
practices (March
2022)
Launched
implementation tool in
new clinical practices
with full leadership
support
Change service
sites
Change the location of
clinical practices to
increase access
7: Provided data
feedback loops to
clinician
champions and
other stakeholders
(September 2022)
Developed interactive
dashboards with key
implementation
measures and shared
with clinician
champions,
administrators, and
leadership
Facilitate relay of
clinical data to
providers
Provide as close to real-
time data as possible about
key measures of
process/outcomes using
integrated modes/channels
of communication in a
way that promotes use of
the targeted innovation
8: Deployed new
role of
“Community
Health Worker” in
the health system
(September 2022)
Created new positions
to connect patients who
reported unmet HRSNs
with essential social
services
Create new
clinical teams
Change who serves on the
clinical team, adding
different disciplines and
different skills to make it
more likely that the
clinical innovation is
delivered (or is more
successfully delivered)
https://doi.org/10.1017/cts.2023.652 Published online by Cambridge University Press
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