Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force | Guidelines | JAMA | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Analytic Framework: Screening and Interventions for Social Risk Factors
Analytic Framework: Screening and Interventions for Social Risk Factors

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the questions that the review will address. The questions are depicted by linkages that relate interventions and outcomes. A dashed line indicates a health outcome that immediately follows an intermediate outcome. Additional information available in the USPSTF Procedure Manual.7

Figure 2.  Literature Search Flow Diagram: Screening and Interventions for Social Risk Factors
Literature Search Flow Diagram: Screening and Interventions for Social Risk Factors

GQ indicates general question; SIREN, Social Interventions Research and Evaluation Network.

aArticles reviewed for all GQs.

bReasons for exclusion: Relevance: Study aim not relevant. No link to health care: Study did not have a link to health care system. Setting: Study not conducted in a country rated “very high” on the Human Development Index. Intervention: Study did not contain an included intervention type. Population: Study only included patients with specific medical conditions. Social risk domain: Study did not include at least 1 target social risk domain. Study design: Study did not use an included design. Abstract only: Full-text publication not available.

Figure 3.  Number of Studies by Social Risk Domain and Outcome Category (n = 68)
Number of Studies by Social Risk Domain and Outcome Category (n = 68)
Table 1.  Social Risk Domains Addressed by Study Design
Social Risk Domains Addressed by Study Design
Table 2.  Social Risk Domains in Pediatric and Adult Studies
Social Risk Domains in Pediatric and Adult Studies
Table 3.  Outcomes in Pediatric and Adult Studies
Outcomes in Pediatric and Adult Studies
Table 4.  Most Commonly Cited Potential Implementation Challenges and Solutionsa
Most Commonly Cited Potential Implementation Challenges and Solutionsa
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    US Preventive Services Task Force
    September 1, 2021

    Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force

    Author Affiliations
    • 1Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
    • 2Center for Healthcare Policy and Research, University of California, Davis, Sacramento
    • 3Department of Family and Community Medicine, University of California, San Francisco
    JAMA. Published online September 1, 2021. doi:10.1001/jama.2021.12825

    Importance  Evidence-based guidance is limited on how clinicians should screen for social risk factors and which interventions related to these risk factors improve health outcomes.

    Objective  To describe research on screening and interventions for social risk factors to inform US Preventive Services Task Force considerations of the implications for its portfolio of recommendations.

    Data Sources  Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Sociological Abstracts, and Social Services Abstracts (through 2018); Social Interventions Research and Evaluation Network evidence library (January 2019 through May 2021); surveillance through May 21, 2021; interviews with 17 key informants.

    Study Selection  Individual-level and health care system–level interventions with a link to the health care system that addressed at least 1 of 7 social risk domains: housing instability, food insecurity, transportation difficulties, utility needs, interpersonal safety, education, and financial strain.

    Data Extraction and Synthesis  One investigator abstracted data from studies and a second investigator evaluated data abstractions for completeness and accuracy; key informant interviews were recorded, transcribed, summarized, and integrated with evidence from the literature; narrative synthesis with supporting tables and figures.

    Main Outcomes and Measures  Validity of multidomain social risk screening tools; all outcomes reported for social risk–related interventions; challenges or unintended consequences of screening and interventions.

    Results  Many multidomain social risk screening tools have been developed, but they vary widely in their assessment of social risk and few have been validated. This technical brief identified 106 social risk intervention studies (N = 5 978 596). Of the interventions studied, 73 (69%; n = 127 598) addressed multiple social risk domains. The most frequently addressed domains were food insecurity (67/106 studies [63%], n = 141 797), financial strain (52/106 studies [49%], n = 111 962), and housing instability (63/106 studies [59%], n = 5 881 222). Food insecurity, housing instability, and transportation difficulties were identified by key informants as the most important social risk factors to identify in health care. Thirty-eight studies (36%, n = 5 850 669) used an observational design with no comparator, and 19 studies (18%, n = 15 205) were randomized clinical trials. Health care utilization measures were the most commonly reported outcomes in the 68 studies with a comparator (38 studies [56%], n = 111 102). The literature and key informants described many perceived or potential challenges to implementation of social risk screening and interventions in health care.

    Conclusions and Relevance  Many interventions to address food insecurity, financial strain, and housing instability have been studied, but more randomized clinical trials that report health outcomes from social risk screening and intervention are needed to guide widespread implementation in health care.


    Social conditions and the structural forces that shape them underlie preventable disparities in many health outcomes. In 2018, there were an estimated 38.1 million people living in poverty in the US,1 and an estimated 1.42 million people experienced sheltered homelessness in 2016.2 Identifying and addressing patients’ experiences of socioeconomic adversity is increasingly the focus of many national health system efforts.3 However, evidence-based guidance is limited on how clinicians should screen for social risk factors and whether health care–initiated interventions related to these risk factors improve health outcomes.

    Social determinants of health are neither inherently positive nor negative but instead encompass the wide range of social and economic conditions that shape health outcomes for individuals and communities.4-6 The downstream manifestations of those forces are experienced by individuals as either social assets or social risk factors. To be consistent with prior work that has helped shape this emerging area of health services research, the term social risk factors is used in this article to refer to measurable and intervenable individual-level social and economic conditions that are shaped by broader determinants of health.6 Furthermore, since social risk factors captured by screening tools are not always reflective of patient priorities or perceived needs, the term social needs is used to more narrowly refer to instances when patients have indicated interest in assistance related to social risks.6

    The US Preventive Services Task Force (USPSTF) makes evidence-based recommendations for primary care preventive services. This technical brief aimed to describe the evidence base for social risk screening and interventions and present an overview of implementation challenges in health care to inform USPSTF considerations of the implications for its portfolio of recommendations. It was not intended to systematically review the effectiveness of social risk screening and interventions or to serve as the basis for a USPSTF clinical practice recommendation.

    Scope of Technical Brief

    This technical brief addressed 5 guiding questions (GQs) as shown in Figure 1. Detailed methods, including search strategies, detailed inclusion criteria, and excluded studies, are publicly available in the full technical brief.8

    Data Sources and Searches

    For GQ1, a search for available screening tools was not conducted because a 2019 review was identified that addressed this question.9 The review included randomized and nonrandomized study designs describing development or empirical use of screening tools assessing 2 or more social risk domains in US populations published since 2000.

    For GQs 2 through 5, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Sociological Abstracts, and Social Services Abstracts were searched from database inception to December 2018. Searches were supplemented by reviewing reference lists of recent reviews and primary studies and the evidence library on the Social Interventions Research and Evaluation Network (SIREN) website ( through May 10, 2021. Active surveillance was conducted via targeted journal searches through May 21, 2021. Literature search results were managed using DistillerSR systematic literature review software (Evidence Partners). A search for conference abstracts and proceedings and other preliminary, unpublished study findings was also conducted.

    Semistructured telephone interviews were conducted with 17 key informants to better understand current clinical context and implementation challenges. Key informants were identified from the SIREN Research Advisory Committee; the National Academies of Sciences, Engineering, and Medicine Committee on Integrating Social Needs Care into the Delivery of Healthcare; and researchers currently conducting studies and actively publishing in the field. These experts represent primary care, policy, research, patient advocacy, social services, public health, federal agency, and payer perspectives, and their work addresses many social risk domains, disadvantaged populations, and health care and community settings. Many clinicians who directly provide patient care and health system representatives were recruited to obtain multiple perspectives on practice variations, issues with implementation, and current clinical context. Two sets of interview questions were used—one for researchers that focused on the evidence base and one for implementation experts that focused on implementation of social risk screening and interventions (eMethods in the Supplement).

    Study Selection

    The abstracts of 17 283 identified articles were reviewed against a priori eligibility criteria (Figure 2). Two investigators then independently evaluated the full text of 545 potentially relevant articles. Studies of patients of all ages conducted in the general population were included. Studies targeting persons with a specific disease were excluded because these studies are typically focused on management of the particular condition and are not applicable to other patients. However, studies that recruited patients with 1 or more unspecified chronic illnesses were included. Interventions were included if they addressed at least 1 of the target social risk domains: housing instability, food insecurity, transportation difficulties, utility needs, aspects of interpersonal safety that are not already addressed by USPSTF recommendations, education, and financial strain. The target social risk domains were aligned to those in the Centers for Medicare & Medicaid Services Accountable Health Communities Model because these are modifiable social risk domains for which there are primary care–referable interventions available to most patients.10 Interventions at the individual and health care system levels targeting single or multiple social risk domains were included. Included studies had to have a link to the health care system.

    Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies; cohort, case-control, observational, and pre-post studies; and case series were included for GQ2 and GQ3. For GQ4, all study designs were included except case reports. For GQ5, all study designs except case reports, editorials, and reviews were included. No studies were excluded based on outcomes reported.

    Data Extraction and Synthesis

    For GQ1, the results of the 2019 systematic review on social risk screening tools9 were summarized, including the social risk domains addressed. Variation in the tools’ assessment of the social risk domains was summarized by examining the phrasing of questions across tools. The screening tools used in studies included for GQ2 with a screening component were recorded and summarized.

    For GQs 2 through 5, data abstraction forms were designed to gather pertinent information from each article that met inclusion criteria, including participant, intervention, and study characteristics. One investigator abstracted information into the forms, and a second investigator evaluated data abstractions for completeness and accuracy. Disagreements were resolved by consensus. As stated above, the purpose of the technical brief was to describe the characteristics of the evidence base rather than to critically appraise and synthesize the effectiveness of available studies. As such, following technical brief methodology, the risk of study bias was not rated and the strength of the evidence was not graded. The evidence for each GQ was narratively synthesized, with supporting summary tables and figures to characterize the identified evidence. The types of outcomes reported in studies were abstracted. The results (eg, effect sizes) were not abstracted because the effectiveness of screening and interventions was outside the scope of the project. All interviews with key informants were recorded and transcribed, and responses were summarized and integrated with evidence from the literature for each GQ.

    Social Risk Screening Tools

    Guiding Question 1. What are the available multidomain screening tools to identify social risk and what social risk domains do they identify? How valid are these tools? How does measurement of specific social risk domains vary by screening tool?

    The 2019 systematic review9 identified available multidomain social risk screening tools, evaluated the degree to which gold standard methods were used in their development, and summarized the available psychometric and pragmatic evidence for the tools. Eighteen tools included in the review are intended for use in primary care settings and address at least 1 of the target social risk domains. The number of questions in these tools ranged from 7 to 118, and administration time ranged from 5 to 25 minutes. The most frequently included social risk domains in the tools were food insecurity, intimate partner violence, housing instability, financial strain, education, and social isolation.

    Only 7 tools had reliability and validity testing data, and in subsequent empirical use, 71% of the tools had been modified from their original form, making it difficult to draw conclusions about their validity. The authors of the review concluded that there were currently no multidomain social risk screening tools with evidence that they can accurately identify social risk, detect changes in social risk, and measure intervention effects.

    For the technical brief, the way in which the 18 tools assess target social risk domains was examined. Twelve tools frame 1 or more questions in terms of “concerns,” “worries,” “problems,” and/or “troubles” to detect patient-identified social needs; only 5 tools ask whether patients would like help with needs they have identified. Tools that address food insecurity generally inquire whether patients or families have enough food; 3 tools also ask about intake of fruits and vegetables or healthy food. Legal tools ask whether respondents are eligible for or have previously been denied Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or Supplemental Nutrition Assistance Program (SNAP) benefits. Questions regarding housing address current housing status, housing quality, and concerns about future homelessness. Five of the 9 tools that assess transportation needs do so by asking whether respondents are able to attend medical appointments. Three tools ask about continuing education needs, and 3 focus on education in the context of health care (eg, reading pharmacy instructions or medical pamphlets). Seven tools addressing financial strain ask about ability to cover basic necessities (food, housing, medical care, heat) or “make ends meet,” and 2 tools include items on income and work status.

    Key informants reported using a variety of social risk screening tools, many of which were developed by their organization. They reported selecting screening tools because they were clinically validated, had a limited time burden, would result in nationally comparative data, met organizational needs, or incorporated the most important patient needs. Thirteen key informants named specific social needs they consider the most important to identify in health care. The most frequently cited social needs were food security (cited by 8 key informants) and housing and transportation (both cited by 6 key informants). Many noted that these social needs are important because they are the most actionable within the health care setting or the most critical to well-being. Key informants also recognized that patients should define the social needs that are most important to them and that the most important issues differ by community.

    Information about what screening tools have been used in studies comes from the evidence included for GQ2. Forty-eight of the 106 studies included for GQ2 had a screening component, with 1 or more screening tools used.11-58 The most frequently used screening tool was the 2-item Hunger Vital Sign tool59,60 (n = 15), followed by the US Department of Agriculture Household Food Security measure61 (n = 4), Health Leads62 (n = 4), and WE CARE12,39 (n = 2). The Homeless Screening Clinical Reminder,36 the Children’s HealthWatch survey,63 iScreen,64 the Cutt 3-item Housing Insecurity tool,65 PRAPARE,66 and the Legal Health Check-up survey67 were each used in 1 study. Some of these tools address only a single domain and so were not included in the 2019 review. Twenty-one studies used a study-developed screening tool; of these tools, some were developed de novo while others were modifications of existing tools, supporting the finding in the 2019 review that the majority of tools were modified when used after development.

    Social Risk Interventions

    Guiding Question 2. What social risk–related interventions have been evaluated? What are the characteristics of the studies that have evaluated these interventions and what outcomes do they report?

    One-hundred six studies (n = 5 978 596)11-58,68-125 met inclusion criteria (Figure 2), including 19 RCTs, 15 cohort studies, 34 pre-post studies, and 38 observational studies without a comparator. Participant, intervention, and study characteristics for included studies, categorized by social risk domain targeted, are presented in eTables 1 through 3 in the Supplement.

    Participant Characteristics

    Thirty studies11,12,14-16,18-20,23,25,29,31,33,34,39,42,44,47,49-51,54,57,81,99,101,107,114,123,125 (n = 65 142) enrolled only children and adolescents (and their caregivers), and 67 studies13,21,22,24,26-28,30,32,35-37,41,43,45,48,52,53,55,56,58,68-76,78,79,82-88,90-92,94-98,100,102-105,108-113,115-122,124 (n = 5 909 541)) enrolled only adults, including older adults (ie, 18 years and older). Five studies17,38,40,89,106 enrolled children and adults (n = 2633), 3 studies77,80,93 enrolled participants of all ages (n = 1280), and 1 study46 enrolled children/adolescents and older adults (n not reported). Fifty-four studies11,14-18,20,22,23,25-29,31-35,38,39,43,44,46-51,54-58,68,71-73,76,78,85,96,98,109,112,113,116,117,121-123,126-128 (n = 120 245) recruited a general, nontargeted patient population; all other studies (n = 5 858 351) targeted patients with particular demographic, medical, or social risk characteristics. Participants were most frequently selected based on specific social risk(s) (eg, homeless, low income) (22 studies, n = 25837).13,19,30,41,70,75,77,80,89,93-95,97,101-103,105,108,110,111,114,118

    Intervention Characteristics

    The majority of studies targeted patients, caregivers, or both (94 studies, n = 5 970 733),11-20,23-26,28-32,34-38,40,42-58,70,72,74-90,92-118,120-125 and 12 studies21,22,27,33,39,41,68,69,71,73,91,119 (n = 7963) targeted physicians or other clinicians. Sixty-nine percent of interventions (73 interventions, n = 127 598) addressed multiple social risk domains (range, 2-14; mode, 8).11-13,17,19,20,22-27,30,31,35,38-45,47-49,51-53,55,68,70,71,73-75,77-82,84,85,88-90,92,93,95-98,100-109,111,114-120,124,125 Many of the social risk domains addressed in multidomain interventions were nontarget domains, such as health care and medication access/affordability, substance use, and employment. Looking at single-domain interventions and the individual target domains included in multidomain interventions, 67 (63%, n = 141 797) address food insecurity,11,12,14,15,17,18,20-29,31-35,37-39,41-58,68,69,71,73,74,79,88,90,91,93,94,96,97,101,105,109-111,115-117,119,123-125 63 (59%, n = 5 881 222) address housing instability,11-13,17,19,20,22-27,30,31,36,38-43,45,47-49,51-53,55,68,71,73-75,77,80,84,88-90,92,93,95,97,100-106,108,109,111,114-120,124,125 52 (49%, n = 111 962) address financial strain,11,13,17,20,22,23,25-27,30,38,45,47-49,53,55,68,70,72-75,77-85,88,89,92,93,95,97-99,101,103,104,107,111,112,114,115,117,121,124,125 35 (33%, n = 101 409) address transportation needs,11,13,20,24,35,41,43,45,47-49,51,53,71,74,81,82,86-88,90,93,97,98,100,104,109,113,115,117,119,120,122,124,125 27 (25%, n = 74 960) address education,12,13,20,22,23,25,26,30,38-43,45,47,48,76,80,81,88,92,101,106,115,116,125 22 (21%, n = 75 851) address utility needs,11,12,16,17,20,23,25,27,41,43,45,47-49,51-53,78,88,90,116,119 and 8 (8%, n = 9650) address interpersonal violence.13,26,38,40,48,49,51,106

    Twenty-four studies24,30,52,79-82,84,85,88,89,92,93,97,98,100,103-105,109,111,118,120,124 (n = 43 522) evaluated interventions that addressed 1 or more social risks but also included 1 or more other components related to medical management. In these studies, it is not clear whether outcomes are due to the effects of the social risk component(s) or these other elements. The three most frequently included nonsocial components were case management or care coordination, in-home health care, and health education.

    Study Characteristics

    The majority of studies were conducted in primary care (58 studies, n = 107 360),12,14-26,28-31,33-35,37-39,41-44,47,48,51,55,56,68-73,75,77,78,82,83,85-87,89,93,96,97,99,101,110,112,117,121,124 followed by multiple settings (15 studies, n = 27 650),11,54,57,58,80,88,95,100,107-109,114,116,120,125 emergency departments (10 studies, n = 4004),13,40,50,53,76,84,91,92,103,123 inpatient hospitals (7 studies, n = 5199),32,74,98,102,105,106,111,120 homes (6 studies, n = 6344),79,81,90,94,104,115 outpatient clinics (6 studies, n = 5 792 469),27,36,46,113,119,122 telephone or web-based care (2 studies, n = 34948),45,52 urgent care (1 study, n = 611),49 and transitional housing (1 study, n = 11).118

    Thirty-six percent of studies (38 studies, n = 5 850 669)14,15,19,20,23,24,26,28,31-34,36,38,41,43,47,48,50-53,55,57,58,70,73,77,79,82,83,88,93,95,99,107,112,123 used an observational design with no comparator. Many of these were descriptions of feasibility testing with small cohorts. The most common study design with a comparator was pre-post (34 studies, n = 46 707),16,21,22,25,27,35,40,42,46,54,56,68,69,71,72,75,76,84,85,90,91,96,97,100,101,108,111,113,115,118,120-122,125 followed by RCTs (19 studies, n = 15 205)11,12,17,29,39,49,74,78,81,89,92,98,102-104,109,114,116,119 and cohort studies (15 studies, n = 66 015).13,18,30,37,44,45,80,86,87,94,105,106,110,117,124 Table 1 shows the number of studies addressing the social risk domains by study design. Fifteen (n = 12 893) of the 19 RCTs addressed housing instability,11,12,17,39,49,74,89,92,102-104,109,114,116,119 12 (n = 7677) addressed financial strain,11,17,49,74,78,81,89,92,98,103,104,114 10 (n = 10 317) addressed food insecurity,11,12,17,29,39,49,74,109,116,119 8 (n = 10 888) addressed transportation needs,11,49,74,81,98,104,109,119 7 (n = 8540) addressed utility needs,11,12,17,49,78,116,119 5 (n = 2781) addressed education,12,39,81,92,116 and 1 (n = 611) addressed interpersonal violence.49

    The outcomes reported in studies were grouped into 6 categories adapted from a recent review of social risk interventions129: process, social risk, physiological and behavioral health, health care utilization, cost, and clinician outcomes. Some of the outcomes in the physiological and behavioral health outcomes category (eg, changes in substance use or dietary intake) do not fit the standard USPSTF definition of a health outcome—ie, outcomes that are experienced or felt by patients and affect patients’ length or quality of life. This is an important consideration for the USPSTF, since evidence for an intervention’s effect on health outcomes is the basis for USPSTF preventive service recommendations.130

    Of the 68 studies with a comparator, 38 studies (n = 111 102)13,17,18,30,40,45,72,74,76,80,81,84-87,89,94,97,98,100-106,108-111,113,114,117-120,122,124 reported health care utilization outcomes (eg, emergency department visits and inpatient admissions), followed by physiological and behavioral health outcomes (eg, mental health status and changes in substance use), reported in in 32 studies (n = 34 058).11,13,17,18,30,35,37,42,44,49,54,72,74,75,78,80,81,84,89,92,96,101-103,105,106,108,109,114-116,125 Twenty-seven studies (n = 27 255)11-13,16,17,29,30,40,42,49,54,56,72,78,80,81,84,91,96,101,103,106,108,111,114,115,121 reported social risk outcomes (eg, resolution of food insecurity), 21 studies (n = 14 120)12,13,18,21,22,25,27,29,35,37,39,40,42,46,68,69,72,91,101,104,116 reported process outcomes (eg, referrals or resources provided), 15 (n = 22 985) studies72,80,81,84,85,90,94,100,101,103,108,110,111,118,120 reported cost outcomes (eg, return on investment), and 6 studies (n = 5731)22,40,68,69,71,119 reported clinician outcomes (eg, confidence in social risk knowledge and screening). Six RCTs (n = 4182)11,12,29,39,104,116 reported process outcomes, 9 RCTs (n = 5639)11,12,17,29,49,78,81,103,114 reported social risk outcomes, 13 RCTs (n = 8237)11,17,49,74,78,81,89,92,102,103,109,114,116 reported physiological and behavioral health outcomes, 11 RCTs (n = 10 859)17,74,81,89,98,102-104,109,114,119 reported health care use outcomes, 2 RCTs (n = 1791)81,103 reported cost outcomes, and 1 RCT (n = 4917)119 reported clinician outcomes.

    To investigate whether social risk interventions that focus on children and their families differ from those targeting adults, a comparison of the social risk domains addressed (Table 2) and outcomes reported (Table 3) for pediatric and adult studies was conducted. Food insecurity and housing instability were the most frequently addressed domains in both pediatric and adult studies. Health care utilization outcomes were reported in 30 of 67 adult studies (45%) but in only 4 of 30 pediatric studies (13%), while physiological and behavioral health outcomes were reported in a similar percentage of adult and pediatric studies (21/67 adult studies [31%] and 10/30 pediatric studies [33%]).

    Figure 3 shows the number of studies that addressed each target social risk domain and the type of outcomes reported in the 68 studies with a comparator. The largest number of studies addressed housing instability and financial strain with health care utilization and physiological and behavioral health outcomes reported, followed by food insecurity with process and physiological and behavioral health outcomes reported and transportation needs with health care utilization outcomes reported.

    Effects of Improvements in Intermediate Outcomes on Health Outcomes

    Guiding Question 3. What are the effects of improvements in process outcomes, health care utilization outcomes, or social risk outcomes on physiological and behavioral health outcomes?

    Since evidence for intervention effects on health outcomes is often lacking, the USPSTF considers the relationship between changes in intermediate outcomes and changes in health outcomes when evaluating the effectiveness of an intervention.130 Although most studies that reported physiological and behavioral health outcomes also reported other outcomes, only 4 studies reported on the effects of changes in intermediate outcomes (eg, process, social risk, or health care utilization outcomes) on physiological and behavioral health outcomes. Two studies72,83 (n = 981) found improvements in health outcomes (ie, psychosocial aspects of quality of life and well-being scores) in patients whose intermediate outcomes improved after receiving welfare benefits advice in primary care but not in patients without improvement in intermediate outcomes. The other 2 studies11,131 (n = 1957)—one examining provision of targeted information related to community, hospital, or government resources addressing social risks and one examining supportive housing—found no associations between intermediate and health outcomes.

    Challenges of Social Risk Screening and Interventions

    Guiding Question 4. What are the perceived or potential challenges to implementation of widespread screening and interventions for social risk factors within health care? What potential solutions have been proposed to address these challenges?

    Information on perceived or potential challenges to social risk screening and interventions, and proposed solutions to these challenges, was gathered from key informants and a scan of reviews, case studies, other descriptive research, and opinion articles identified in the literature searches. Table 4 shows the most commonly cited patient-, clinician-, health system–, and community-level factors that may present challenges to implementation of social risk screening and interventions in health care settings, and proposed strategies to overcome these challenges.

    Acceptability and Unintended Consequences of Social Risk Screening and Interventions

    Guiding Question 5. What are the challenges or unintended consequences of screening and interventions for social risk factors to patients and clinicians? What is the acceptability of screening for and intervening on social risk factors for patients and clinicians?

    Fifty-two studies13,15,22,25,26,32-34,38,39,44,48,56,68,71,74,76,78,84,98,99,101,107,112,115,116,119,121,123,124,126-128,132,136,150-166 provided data on patient- or clinician-reported satisfaction or challenges after implementation of social risk screening or interventions (eTable 4 in the Supplement).


    Thirty-one articles13,25,38,44,56,68,71,74,76,78,98,101,112,116,121,123,124,126-128,136,150,152-154,156,157,159,160,163 included positive patient reports of satisfaction with and acceptability of screening and interventions, often referring to improvements in the patient-clinician relationship and high comfort levels. Eleven articles32,34,48,99,101,115,119,153,155,159,164 reported on challenges or unintended consequences of screening or intervention for patients, including discomfort (eg, shame about social risks) and confidentiality issues (eg, fear of legal repercussions such as being reported for child maltreatment due to food insecurity). One study found paradoxical effects of improvement in social risks; families who participated in SNAP and increased their earned income had their SNAP benefits reduced or cut off and subsequently faced economic strain that diminished their ability to pay for housing, utilities, health care, or food.155 Two articles reported that there were no adverse effects from the intervention.115,119


    Seventeen of the 18 articles15,33,39,56,68,71,99,107,112,128,132,157-159,161,162,165,166 that reported on clinician satisfaction with screening and interventions were positive, with clinicians stating that screening was not overly time-consuming and led to improvements in the patient-clinician relationship, patient care, and clinician knowledge and competence. The 1 negative report was related to difficulty in incorporating the intervention into clinician schedules.99 Fifteen articles15,22,26,33,34,68,84,119,132,151,159,161,162,165,166 reported on challenges or unintended consequences of social risk screening or interventions for clinicians, including lack of time to conduct screening or follow-up on positive results and inability to track the success of referrals.


    This technical brief identified and described the evidence on social risk screening and interventions. Many multidomain social risk screening tools are available, but few have undergone reliability and validity testing. Food insecurity, housing instability, and transportation difficulties were identified by key informants as the most important social risk factors to identify in health care, and these are 3 of the most frequently addressed social risk domains in the 106 intervention studies identified, along with financial security. Thirty-six percent of studies used an observational design with no comparator, and only 18% of studies were RCTs. Health care utilization measures were the most commonly reported outcomes in studies with a comparator. The literature and key informants described many challenges to implementation of social risk screening and interventions in health care.

    In keeping with the USPSTF focus on recommendations for primary care clinicians about preventive services for asymptomatic people, this technical brief focused on population-based screening in primary care to detect unrecognized social risk factors and interventions to address them. Some experts have argued that screening should only be done when there is the capacity to address identified social risks. Although there is ongoing debate about the merits of screening without social risk–targeted interventions,134 it is nonetheless relevant to note that few existing screening tools assess patients’ interest in assistance for identified social needs.167

    This technical brief was prepared to inform USPSTF efforts to incorporate social risks into its recommendation process. The USPSTF considers services that are provided in or referable from primary care. While screening for social risk factors can be done in primary care clinical settings, many subsequent activities to intervene on social risks involve a referral from the health care team to a non–health care setting, such as public health, social service, and community-based organizations. This requires effective partnerships with these resources, adding a layer of complexity to implementation of social care in clinical settings. This technical brief identified many perceived or potential challenges to the implementation of social risk screening and intervention programs in health care. However, actual unintended consequences from social risk screening and interventions were rare in the studies that reported these outcomes. More data on the challenges encountered during implementation of social risk screening and interventions in health care settings and on ways that these challenges have been addressed successfully would clarify what barriers and solutions need to be considered before scaling implementation efforts.


    This technical brief has several limitations. First, searches and inclusion criteria were limited to studies with the most relevance to the USPSTF scope and purpose. As such, studies in the general population were focused on and studies conducted in patients with a specific disease were excluded. Social risk screening and interventions may have different effects in patients with specific chronic conditions requiring complex management, such as diabetes. Second, studies conducted in countries that are not rated “very high” on the Human Development Index were also excluded, which may have left out a considerable amount of research. Third, other limitations stem from the methods used, given the focus of the technical brief on identifying and describing existing research rather than systematically reviewing the effectiveness of screening and interventions for social risk factors. Critical appraisal was not conducted, and some of the included studies may be of poor quality and would not meet criteria for a USPSTF review and recommendation. Outcomes data were not abstracted and results were not evaluated to determine the effect of interventions on outcomes.


    Many interventions to address food insecurity, financial strain, and housing instability have been studied, but more randomized clinical trials that report health outcomes from social risk screening and intervention are needed to guide widespread implementation in health care.

    Back to top
    Article Information

    Corresponding Author: Michelle Eder, PhD, Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Ave, Portland, OR 97227 (

    Accepted for Publication: July 16, 2021.

    Published Online: September 1, 2021. doi:10.1001/jama.2021.12825

    Author Contributions: Dr Eder had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Eder, Gottlieb, Lin.

    Acquisition, analysis, or interpretation of data: Eder, Henninger, Durbin, Iacocca, Martin, Gottlieb.

    Drafting of the manuscript: Eder, Henninger, Iacocca, Martin.

    Critical revision of the manuscript for important intellectual content: Eder, Durbin, Martin, Gottlieb, Lin.

    Obtained funding: Eder, Lin.

    Administrative, technical, or material support: Eder, Henninger, Durbin, Iacocca, Martin.

    Supervision: Eder, Gottlieb, Lin.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This research was funded under contract HHSA-290-2015-00007-I-EPC5, Task Order 7, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).

    Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the guiding questions and resolve methodologic issues during the conduct of the technical brief. AHRQ had no role in study selection, data extraction, or synthesis. AHRQ staff provided project oversight and reviewed the report to ensure that the analysis met methodological standards. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

    Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Amanda Borsky, DrPH, MPP, and Justin Mills, MD, MPH, at the Agency for Healthcare Research and Quality; members of the USPSTF who contributed to topic discussions; Toyin Ajayi, MD, MPhil (Cityblock Health), Elena Byhoff, MD, MSc (Tufts University School of Medicine), Arvin Garg, MD, MPH (Boston University School of Medicine), Katie Martin, MPA (Health Care Cost Institute), and John Steiner, MD, MPH (Kaiser Permanente Institute for Health Research, Colorado), who provided expert review of the draft technical brief; Rachel Gold, PhD, MPH (Kaiser Permanente Center for Health Research), for expert consultation and review of the draft technical brief; Todd Hannon, MLS, Melinda Davies, MAIS, Katherine Essick, BS, and Debra Burch (Kaiser Permanente Center for Health Research), for library, editorial, and administrative assistance; and Emily S. Walsh, MPH (Kaiser Permanente Care Management Institute), for research support. We also thank the following key informants: Toyin Ajayi, MD, MPhil (Cityblock Health), Dawn Alley, PhD (Center for Medicare and Medicaid Innovation), Andrew Beck, MD, MPH (Cincinnati Children’s Hospital Medical Center), Seth Berkowitz, MD (University of North Carolina at Chapel Hill), Arlene Bierman, MD, MS (Agency for Healthcare Research and Quality), Rosaly Correa-de-Araujo, MD, MSc, PhD (National Institute on Aging), Karen DeSalvo, MD, MPH, MSc (University of Texas), Susan Dreyfus, BS (Alliance for Strong Families and Communities), Eric Fleegler, MD, MPH (Boston Children’s Hospital), Susan Jepson, MPH, BSN (Hennepin County Medical Center), Danielle Jones, MPH (American Academy of Family Physicians), Katie Martin, MPA (Health Care Cost Institute), Ana Penman-Aguilar, PhD, MPH (Centers for Disease Control and Prevention), Robert Phillips, MD, MSPH (American Board of Family Medicine), Kate Sommerfeld, MPA (ProMedica), John Steiner, MD, MPH (Kaiser Permanente Institute for Health Research, Colorado), and Rashi Venkataraman, MS (America’s Health Insurance Plans). USPSTF members, peer reviewers, and key informants did not receive financial compensation for their contributions.

    Additional Information: A draft version of this technical brief underwent external peer review from 5 content experts (Toyin Ajayi, MD, MPhil, Cityblock Health; Elena Byhoff, MD, MSc, Tufts University School of Medicine; Arvin Garg, MD, MPH, Boston University School of Medicine; Katie Martin, MPA, Health Care Cost Institute; and John Steiner, MD, MPH, Kaiser Permanente Institute for Health Research, Colorado). Comments were presented to the USPSTF working group members and were considered in preparing the final technical brief.

    Semega  J, Kollar  M, Creamer  J, Mohanty  A.  Income and Poverty in the United States: 2018. US Census Bureau; 2019.
    The 2016 Annual Homeless Assessment Report (AHAR) to Congress. US Department of Housing and Urban Development. Published 2017. Accessed December 2, 2019.
    Institute of Medicine.  Capturing Social & Behavioral Domains & Measures in Electronic Health Records: Phase 2. National Academies Press; 2014.
    Green  K, Zook  M. When talking about social determinants, precision matters. Health Affairs Blog. October 29, 2019. Accessed July 15, 2021.
    Castrucci  B, Auerbach  J. Meeting individual social needs falls short of addressing social determinants of health. Health Affairs Blog. January 16, 2019. Accessed July 15, 2021.
    Alderwick  H, Gottlieb  LM.  Meanings and misunderstandings: a social determinants of health lexicon for health care systems.   Milbank Q. 2019;97(2):407-419. doi:10.1111/1468-0009.12390PubMedGoogle ScholarCrossref
    Procedure Manual. US Preventive Services Task Force. Published 2018. Accessed July 15, 2021.
    Eder  M, Henninger  M, Durbin  S,  et al.  Screening and Interventions for Social Risk Factors: A Technical Brief to Support the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2021. AHRQ publication 20-05267-EF-1.
    Henrikson  NB, Blasi  PR, Dorsey  CN,  et al.  Psychometric and pragmatic properties of social risk screening tools: a systematic review.   Am J Prev Med. 2019;57(6 suppl 1):S13-S24.Google ScholarCrossref
    Billioux  A, Verlander  K, Anthony  S, Alley  D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. National Academy of Medicine. Published May 30, 2017. Accessed July 20, 2021.
    Gottlieb  LM, Hessler  D, Long  D,  et al.  Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial.   JAMA Pediatr. 2016;170(11):e162521. doi:10.1001/jamapediatrics.2016.2521PubMedGoogle Scholar
    Garg  A, Toy  S, Tripodis  Y, Silverstein  M, Freeman  E.  Addressing social determinants of health at well child care visits: a cluster RCT.   Pediatrics. 2015;135(2):e296-e304. doi:10.1542/peds.2014-2888PubMedGoogle ScholarCrossref
    Losonczy  LI, Hsieh  D, Wang  M,  et al.  The Highland Health Advocates: a preliminary evaluation of a novel programme addressing the social needs of emergency department patients.   Emerg Med J. 2017;34(9):599-605. doi:10.1136/emermed-2015-205662PubMedGoogle ScholarCrossref
    Bottino  CJ, Rhodes  ET, Kreatsoulas  C, Cox  JE, Fleegler  EW.  Food insecurity screening in pediatric primary care: can offering referrals help identify families in need?   Acad Pediatr. 2017;17(5):497-503. doi:10.1016/j.acap.2016.10.006PubMedGoogle ScholarCrossref
    Palakshappa  D, Vasan  A, Khan  S, Seifu  L, Feudtner  C, Fiks  AG.  Clinicians’ perceptions of screening for food insecurity in suburban pediatric practice.   Pediatrics. 2017;140(1):e20170319. doi:10.1542/peds.2017-0319PubMedGoogle Scholar
    Taylor  DR, Bernstein  BA, Carroll  E, Oquendo  E, Peyton  L, Pachter  LM.  Keeping the heat on for children’s health: a successful medical-legal partnership initiative to prevent utility shutoffs in vulnerable children.   J Health Care Poor Underserved. 2015;26(3):676-685. doi:10.1353/hpu.2015.0074PubMedGoogle ScholarCrossref
    Sege  R, Preer  G, Morton  SJ,  et al.  Medical-legal strategies to improve infant health care: a randomized trial.   Pediatrics. 2015;136(1):97-106. doi:10.1542/peds.2014-2955PubMedGoogle ScholarCrossref
    Beck  AF, Henize  AW, Kahn  RS, Reiber  KL, Young  JJ, Klein  MD.  Forging a pediatric primary care-community partnership to support food-insecure families.   Pediatrics. 2014;134(2):e564-e571. doi:10.1542/peds.2013-3845PubMedGoogle ScholarCrossref
    Beck  AF, Klein  MD, Schaffzin  JK, Tallent  V, Gillam  M, Kahn  RS.  Identifying and treating a substandard housing cluster using a medical-legal partnership.   Pediatrics. 2012;130(5):831-838. doi:10.1542/peds.2012-0769PubMedGoogle ScholarCrossref
    Garg  A, Marino  M, Vikani  AR, Solomon  BS.  Addressing families’ unmet social needs within pediatric primary care: the health leads model.   Clin Pediatr (Phila). 2012;51(12):1191-1193. doi:10.1177/0009922812437930PubMedGoogle ScholarCrossref
    Burkhardt  MC, Beck  AF, Conway  PH, Kahn  RS, Klein  MD.  Enhancing accurate identification of food insecurity using quality-improvement techniques.   Pediatrics. 2012;129(2):e504-e510. doi:10.1542/peds.2011-1153PubMedGoogle ScholarCrossref
    Klein  MD, Kahn  RS, Baker  RC, Fink  EE, Parrish  DS, White  DC.  Training in social determinants of health in primary care: does it change resident behavior?   Acad Pediatr. 2011;11(5):387-393. doi:10.1016/j.acap.2011.04.004PubMedGoogle ScholarCrossref
    Garg  A, Sarkar  S, Marino  M, Onie  R, Solomon  BS.  Linking urban families to community resources in the context of pediatric primary care.   Patient Educ Couns. 2010;79(2):251-254. doi:10.1016/j.pec.2009.10.011PubMedGoogle ScholarCrossref
    Clark  CR, Baril  N, Kunicki  M,  et al; REACH 2010 Breast and Cervical Cancer Coalition.  Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women’s Health Demonstration Project.   J Womens Health (Larchmt). 2009;18(5):677-690. doi:10.1089/jwh.2008.0972PubMedGoogle ScholarCrossref
    Selvaraj  K, Ruiz  MJ, Aschkenasy  J,  et al.  Screening for toxic stress risk factors at well-child visits: the Addressing Social Key Questions for Health study.   J Pediatr. 2019;205:244-249. doi:10.1016/j.jpeds.2018.09.004PubMedGoogle ScholarCrossref
    Gold  R, Bunce  A, Cowburn  S,  et al.  Adoption of social determinants of health EHR Tools by community health centers.   Ann Fam Med. 2018;16(5):399-407. doi:10.1370/afm.2275PubMedGoogle ScholarCrossref
    Patel  M, Bathory  E, Scholnick  J, White-Davis  T, Choi  J, Braganza  S.  Resident documentation of social determinants of health: effects of a teaching tool in the outpatient setting.   Clin Pediatr (Phila). 2018;57(4):451-456. doi:10.1177/0009922817728697PubMedGoogle ScholarCrossref
    Smith  S, Malinak  D, Chang  J,  et al.  Implementation of a food insecurity screening and referral program in student-run free clinics in San Diego, California.   Prev Med Rep. 2016;5:134-139. doi:10.1016/j.pmedr.2016.12.007PubMedGoogle ScholarCrossref
    Lane  WG, Dubowitz  H, Feigelman  S, Poole  G.  The effectiveness of food insecurity screening in pediatric primary care.   Int J Child Health Nutr. 2014;3(3):130-138. doi:10.6000/1929-4247.2014.03.03.3PubMedGoogle ScholarCrossref
    Tessaro  I, Campbell  M, O’Meara  C,  et al.  State health department and university evaluation of North Carolina’s Maternal Outreach Worker Program.   Am J Prev Med. 1997;13(6)(suppl):38-44. doi:10.1016/S0749-3797(18)30092-8PubMedGoogle ScholarCrossref
    Higginbotham  K, Davis Crutcher  T, Karp  SM.  Screening for social determinants of health at well-child appointments: a quality improvement project.   Nurs Clin North Am. 2019;54(1):141-148. doi:10.1016/j.cnur.2018.10.009PubMedGoogle ScholarCrossref
    Swavely  D, Whyte  V, Steiner  JF, Freeman  SL.  Complexities of addressing food insecurity in an urban population.   Popul Health Manag. 2019;22(4):300-307. doi:10.1089/pop.2018.0126PubMedGoogle ScholarCrossref
    Stenmark  SH, Steiner  JF, Marpadga  S, Debor  M, Underhill  K, Seligman  H.  Lessons learned from implementation of the Food Insecurity Screening and Referral Program at Kaiser Permanente Colorado.   Perm J. 2018;22:18-093. doi:10.7812/TPP/18-093PubMedGoogle Scholar
    Knowles  M, Khan  S, Palakshappa  D,  et al.  Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings.   J Health Care Poor Underserved. 2018;29(1):181-191. doi:10.1353/hpu.2018.0012PubMedGoogle ScholarCrossref
    Berkowitz  SA, Hulberg  AC, Placzek  H,  et al.  Mechanisms associated with clinical improvement in interventions that address health-related social needs: a mixed-methods analysis.   Popul Health Manag. 2019;22(5):399-405. doi:10.1089/pop.2018.0162PubMedGoogle ScholarCrossref
    Fargo  JD, Montgomery  AE, Byrne  T, Brignone  E, Cusack  M, Gundlapalli  AV.  Needles in a haystack: screening and healthcare system evidence for homelessness.   Stud Health Technol Inform. 2017;235:574-578.PubMedGoogle Scholar
    Morales  ME, Epstein  MH, Marable  DE, Oo  SA, Berkowitz  SA.  Food insecurity and cardiovascular health in pregnant women: results from the Food for Families Program, Chelsea, Massachusetts, 2013-2015.   Prev Chronic Dis. 2016;13:E152. doi:10.5888/pcd13.160212PubMedGoogle Scholar
    Hassan  A, Scherer  EA, Pikcilingis  A,  et al.  Improving social determinants of health: effectiveness of a web-based intervention.   Am J Prev Med. 2015;49(6):822-831. doi:10.1016/j.amepre.2015.04.023PubMedGoogle ScholarCrossref
    Garg  A, Butz  AM, Dworkin  PH, Lewis  RA, Thompson  RE, Serwint  JR.  Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project.   Pediatrics. 2007;120(3):547-558. doi:10.1542/peds.2007-0398PubMedGoogle ScholarCrossref
    Juillard  C, Cooperman  L, Allen  I,  et al.  A decade of hospital-based violence intervention: benefits and shortcomings.   J Trauma Acute Care Surg. 2016;81(6):1156-1161. doi:10.1097/TA.0000000000001261PubMedGoogle ScholarCrossref
    Onyekere  C, Ross  S, Namba  A, Ross  JC, Mann  BD.  Medical student volunteerism addresses patients’ social needs: a novel approach to patient-centered care.   Ochsner J. 2016;16(1):45-49.PubMedGoogle Scholar
    Costich  MA, Peretz  PJ, Davis  JA, Stockwell  MS, Matiz  LA.  Impact of a community health worker program to support caregivers of children with special health care needs and address social determinants of health.   Clin Pediatr (Phila). 2019;58(11-12):1315-1320. doi:10.1177/0009922819851263PubMedGoogle ScholarCrossref
    Buitron de la Vega  P, Losi  S, Sprague Martinez  L,  et al.  Implementing an EHR-based screening and referral system to address social determinants of health in primary care.   Med Care. 2019;57(suppl 6 suppl 2):S133-S139.Google ScholarCrossref
    Hickey  E, Phan  M, Beck  AF, Burkhardt  MC, Klein  MD.  A mixed-methods evaluation of a novel food pantry in a pediatric primary care center.   Clin Pediatr (Phila). 2020;59(3):278-284. doi:10.1177/0009922819900960PubMedGoogle ScholarCrossref
    Schickedanz  A, Sharp  A, Hu  YR,  et al.  Impact of social needs navigation on utilization among high utilizers in a large integrated health system: a quasi-experimental study.   J Gen Intern Med. 2019;34(11):2382-2389. doi:10.1007/s11606-019-05123-2PubMedGoogle ScholarCrossref
    Hager  K, De Kesel Lofthus  A, Balan  B, Cutts  D.  Electronic medical record-based referrals to community nutritional assistance for food-insecure patients.   Ann Fam Med. 2020;18(3):278. doi:10.1370/afm.2530PubMedGoogle ScholarCrossref
    Polk  S, Leifheit  KM, Thornton  R, Solomon  BS, DeCamp  LR.  Addressing the social needs of Spanish- and English-speaking families in pediatric primary care.   Acad Pediatr. 2020;20(8):1170-1176. doi:10.1016/j.acap.2020.03.004PubMedGoogle ScholarCrossref
    Sandhu  S, Xu  J, Blanchard  L,  et al.  A community resource navigator model: utilizing student volunteers to integrate health and social care in a community health center setting.   Int J Integr Care. 2021;21(1):2. doi:10.5334/ijic.5501PubMedGoogle ScholarCrossref
    Gottlieb  LM, Adler  NE, Wing  H,  et al.  Effects of in-person assistance vs personalized written resources about social services on household social risks and child and caregiver health: a randomized clinical trial.   JAMA Netw Open. 2020;3(3):e200701. doi:10.1001/jamanetworkopen.2020.0701PubMedGoogle Scholar
    Cullen  D, Abel  D, Attridge  M, Fein  JA.  Exploring the gap: food insecurity and resource engagement.   Acad Pediatr. 2021;21(3):440-445. doi:10.1016/j.acap.2020.08.005PubMedGoogle ScholarCrossref
    Fiori  K, Patel  M, Sanderson  D,  et al.  From policy statement to practice: integrating social needs screening and referral assistance with community health workers in an urban academic health center.   J Prim Care Community Health. 2019;10:2150132719899207. doi:10.1177/2150132719899207PubMedGoogle Scholar
    Khidir  H, DeLuca  M, Macias-Konstantopoulos  WL,  et al.  The health and social needs of patients discharged from the emergency department with suspected COVID-19.   Public Health Rep. 2021;136(3):309-314. doi:10.1177/0033354920982579PubMedGoogle ScholarCrossref
    Kulie  P, Steinmetz  E, Johnson  S, McCarthy  ML.  A health-related social needs referral program for Medicaid beneficiaries treated in an emergency department.   Am J Emerg Med. 2021;47:119-124. doi:10.1016/j.ajem.2021.03.069PubMedGoogle ScholarCrossref
    Jones  LJ, VanWassenhove-Paetzold  J, Thomas  K,  et al.  Impact of a fruit and vegetable prescription program on health outcomes and behaviors in young Navajo children.   Curr Dev Nutr. 2020;4(8):a109. doi:10.1093/cdn/nzaa109PubMedGoogle ScholarCrossref
    Agarwal  G, Pirrie  M, Edwards  D,  et al.  Legal needs of patients attending an urban family practice in Hamilton, Ontario, Canada: an observational study of a legal health clinic.   BMC Fam Pract. 2020;21(1):267. doi:10.1186/s12875-020-01339-yPubMedGoogle ScholarCrossref
    Aiyer  JN, Raber  M, Bello  RS,  et al.  A pilot food prescription program promotes produce intake and decreases food insecurity.   Transl Behav Med. 2019;9(5):922-930. doi:10.1093/tbm/ibz112PubMedGoogle ScholarCrossref
    Fritz  CQ, Thomas  J, Brittan  MS, Mazzio  E, Pitkin  J, Suh  C.  Referral and resource utilization among food insecure families identified in a pediatric medical setting.   Acad Pediatr. 2021;21(3):446-454. doi:10.1016/j.acap.2020.11.019PubMedGoogle ScholarCrossref
    Kelly  C, Maytag  A, Allen  M, Ross  C.  Results of an initiative supporting community-based organizations and health care clinics to assist individuals with enrolling in SNAP.   J Public Health Manag Pract. Published online November 16, 2020. doi:10.1097/PHH.0000000000001208PubMedGoogle Scholar
    Council on Community Pediatrics.  Promoting food security for all children.   Pediatrics. 2015;136(5):e1431-e1438. doi:10.1542/peds.2015-3301PubMedGoogle ScholarCrossref
    Hager  ER, Quigg  AM, Black  MM,  et al.  Development and validity of a 2-item screen to identify families at risk for food insecurity.   Pediatrics. 2010;126(1):e26-e32. doi:10.1542/peds.2009-3146PubMedGoogle ScholarCrossref
    Bickel  G, Nord  M, Price  C, Hamilton  W, Cook  J.  Guide to Measuring Household Food Security. US Dept of Agriculture; 2000.
    The Health Leads Screening Toolkit. Heath Leads. Published 2018. Accessed November 11, 2019.
    Children’s HealthWatch website. Accessed November 11, 2019.
    Gottlieb  L, Hessler  D, Long  D, Amaya  A, Adler  N.  A randomized trial on screening for social determinants of health: the iScreen study.   Pediatrics. 2014;134(6):e1611-e1618. doi:10.1542/peds.2014-1439PubMedGoogle ScholarCrossref
    Cutts  DB, Meyers  AF, Black  MM,  et al.  US housing insecurity and the health of very young children.   Am J Public Health. 2011;101(8):1508-1514. doi:10.2105/AJPH.2011.300139PubMedGoogle ScholarCrossref
    PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences. National Association of Community Health Centers. Published September 6, 2016. Accessed October 23, 2019.
    Legal Health Check-up. Halton Legal Clinic. Published 2014. Accessed July 15, 2021.
    Klein  MD, Alcamo  AM, Beck  AF,  et al.  Can a video curriculum on the social determinants of health affect residents’ practice and families’ perceptions of care?   Acad Pediatr. 2014;14(2):159-166. doi:10.1016/j.acap.2013.11.002PubMedGoogle ScholarCrossref
    Smith  S, Malinak  D, Chang  J, Schultz  A, Brownell  K.  Addressing food insecurity in family medicine and medical education.   Fam Med. 2017;49(10):765-771.PubMedGoogle Scholar
    Jones  MK, Bloch  G, Pinto  AD.  A novel income security intervention to address poverty in a primary care setting: a retrospective chart review.   BMJ Open. 2017;7(8):e014270. doi:10.1136/bmjopen-2016-014270PubMedGoogle Scholar
    Real  FJ, Beck  AF, Spaulding  JR, Sucharew  H, Klein  MD.  Impact of a neighborhood-based curriculum on the helpfulness of pediatric residents’ anticipatory guidance to impoverished families.   Matern Child Health J. 2016;20(11):2261-2267. doi:10.1007/s10995-016-2133-7PubMedGoogle ScholarCrossref
    Woodhead  C, Khondoker  M, Lomas  R, Raine  R.  Impact of co-located welfare advice in healthcare settings: prospective quasi-experimental controlled study.   Br J Psychiatry. 2017;211(6):388-395. doi:10.1192/bjp.bp.117.202713PubMedGoogle ScholarCrossref
    Wilder  V, Gagnon  M, Olatunbosun  B,  et al.  Community health needs assessment as a teaching tool in a family medicine residency.   Fam Med. 2016;48(8):635-637.PubMedGoogle Scholar
    Kangovi  S, Mitra  N, Grande  D,  et al.  Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial.   JAMA Intern Med. 2014;174(4):535-543. doi:10.1001/jamainternmed.2013.14327PubMedGoogle ScholarCrossref
    Ryan  AM, Kutob  RM, Suther  E, Hansen  M, Sandel  M.  Pilot study of impact of medical-legal partnership services on patients’ perceived stress and wellbeing.   J Health Care Poor Underserved. 2012;23(4):1536-1546. doi:10.1353/hpu.2012.0179PubMedGoogle ScholarCrossref
    Herman  A, Young  KD, Espitia  D, Fu  N, Farshidi  A.  Impact of a health literacy intervention on pediatric emergency department use.   Pediatr Emerg Care. 2009;25(7):434-438. doi:10.1097/PEC.0b013e3181ab78c7PubMedGoogle ScholarCrossref
    Teufel  JA, Brown  SL, Thorne  W, Goffinet  DM, Clemons  L.  Process and impact evaluation of a legal assistance and health care community partnership.   Health Promot Pract. 2009;10(3):378-385. doi:10.1177/1524839907312702PubMedGoogle ScholarCrossref
    Mackintosh  J, White  M, Howel  D,  et al.  Randomised controlled trial of welfare rights advice accessed via primary health care: pilot study [ISRCTN61522618].   BMC Public Health. 2006;6:162. doi:10.1186/1471-2458-6-162PubMedGoogle ScholarCrossref
    Yaggy  SD, Michener  JL, Yaggy  D,  et al.  Just for Us: an academic medical center–community partnership to maintain the health of a frail low-income senior population.   Gerontologist. 2006;46(2):271-276. doi:10.1093/geront/46.2.271PubMedGoogle ScholarCrossref
    Graham-Jones  S, Reilly  S, Gaulton  E.  Tackling the needs of the homeless: a controlled trial of health advocacy.   Health Soc Care Community. 2004;12(3):221-232. doi:10.1111/j.1365-2524.2004.00491.xPubMedGoogle ScholarCrossref
    Olds  DL.  Prenatal and infancy home visiting by nurses: from randomized trials to community replication.   Prev Sci. 2002;3(3):153-172. doi:10.1023/A:1019990432161PubMedGoogle ScholarCrossref
    Forti  EM, Koerber  M.  An outreach intervention for older rural African Americans.   J Rural Health. 2002;18(3):407-415. doi:10.1111/j.1748-0361.2002.tb00905.xPubMedGoogle ScholarCrossref
    Abbott  S, Hobby  L.  Welfare benefits advice in primary care: evidence of improvements in health.   Public Health. 2000;114(5):324-327. doi:10.1016/S0033-3506(00)00356-5PubMedGoogle Scholar
    Okin  RL, Boccellari  A, Azocar  F,  et al.  The effects of clinical case management on hospital service use among ED frequent users.   Am J Emerg Med. 2000;18(5):603-608. doi:10.1053/ajem.2000.9292PubMedGoogle ScholarCrossref
    Vest  JR, Harris  LE, Haut  DP, Halverson  PK, Menachemi  N.  Indianapolis provider’s use of wraparound services associated with reduced hospitalizations and emergency department visits.   Health Aff (Millwood). 2018;37(10):1555-1561. doi:10.1377/hlthaff.2018.0075PubMedGoogle ScholarCrossref
    Chaiyachati  KH, Hubbard  RA, Yeager  A,  et al.  Rideshare-based medical transportation for Medicaid patients and primary care show rates: a difference-in-difference analysis of a pilot program.   J Gen Intern Med. 2018;33(6):863-868. doi:10.1007/s11606-018-4306-0PubMedGoogle ScholarCrossref
    Chaiyachati  KH, Hubbard  RA, Yeager  A,  et al.  Association of rideshare-based transportation services and missed primary care appointments: a clinical trial.   JAMA Intern Med. 2018;178(3):383-389. doi:10.1001/jamainternmed.2017.8336PubMedGoogle ScholarCrossref
    Kwan  BM, Rockwood  A, Bandle  B, Fernald  D, Hamer  MK, Capp  R.  Community health workers: addressing client objectives among frequent emergency department users.   J Public Health Manag Pract. 2018;24(2):146-154. doi:10.1097/PHH.0000000000000540PubMedGoogle ScholarCrossref
    Kenyon  S, Jolly  K, Hemming  K,  et al.  Lay support for pregnant women with social risk: a randomised controlled trial.   BMJ Open. 2016;6(3):e009203. doi:10.1136/bmjopen-2015-009203PubMedGoogle Scholar
    Pruitt  Z, Emechebe  N, Quast  T, Taylor  P, Bryant  K.  Expenditure reductions associated with a social service referral program.   Popul Health Manag. 2018;21(6):469-476. doi:10.1089/pop.2017.0199PubMedGoogle ScholarCrossref
    Martel  ML, Klein  LR, Hager  KA, Cutts  DB.  Emergency department experience with novel electronic medical record order for referral to food resources.   West J Emerg Med. 2018;19(2):232-237. doi:10.5811/westjem.2017.12.35211PubMedGoogle ScholarCrossref
    Iglesias  K, Baggio  S, Moschetti  K,  et al.  Using case management in a universal health coverage system to improve quality of life of frequent emergency department users: a randomized controlled trial.   Qual Life Res. 2018;27(2):503-513. doi:10.1007/s11136-017-1739-6PubMedGoogle ScholarCrossref
    Gunderson  JM, Wieland  ML, Quirindongo-Cedeno  O,  et al.  Community health workers as an extension of care coordination in primary care: a community-based cosupervisory model.   J Ambul Care Manage. 2018;41(4):333-340. doi:10.1097/JAC.0000000000000255PubMedGoogle ScholarCrossref
    Berkowitz  SA, Terranova  J, Hill  C,  et al.  Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries.   Health Aff (Millwood). 2018;37(4):535-542. doi:10.1377/hlthaff.2017.0999PubMedGoogle ScholarCrossref
    Tsai  J, Middleton  M, Villegas  J,  et al.  Medical-legal partnerships at Veterans Affairs medical centers improved housing and psychosocial outcomes for vets.   Health Aff (Millwood). 2017;36(12):2195-2203. doi:10.1377/hlthaff.2017.0759PubMedGoogle ScholarCrossref
    Cohen  AJ, Richardson  CR, Heisler  M,  et al.  Increasing use of a healthy food incentive: a waiting room intervention among low-income patients.   Am J Prev Med. 2017;52(2):154-162. doi:10.1016/j.amepre.2016.11.008PubMedGoogle ScholarCrossref
    O’Toole  TP, Johnson  EE, Aiello  R, Kane  V, Pape  L.  Tailoring care to vulnerable populations by incorporating social determinants of health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” program.   Prev Chronic Dis. 2016;13:E44. doi:10.5888/pcd13.150567PubMedGoogle Scholar
    Bronstein  LR, Gould  P, Berkowitz  SA, James  GD, Marks  K.  Impact of a social work care coordination intervention on hospital readmission: a randomized controlled trial.   Soc Work. 2015;60(3):248-255. doi:10.1093/sw/swv016PubMedGoogle ScholarCrossref
    Parthasarathy  P, Dailey  DE, Young  ME, Lam  C, Pies  C.  Building economic security today: making the health-wealth connection in Contra Costa county’s maternal and child health programs.   Matern Child Health J. 2014;18(2):396-404. doi:10.1007/s10995-013-1309-7PubMedGoogle ScholarCrossref
    Raven  MC, Doran  KM, Kostrowski  S, Gillespie  CC, Elbel  BD.  An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study.   BMC Health Serv Res. 2011;11:270. doi:10.1186/1472-6963-11-270PubMedGoogle ScholarCrossref
    Weintraub  D, Rodgers  MA, Botcheva  L,  et al.  Pilot study of medical-legal partnership to address social and legal needs of patients.   J Health Care Poor Underserved. 2010;21(2)(suppl):157-168.PubMedGoogle Scholar
    Sadowski  LS, Kee  RA, VanderWeele  TJ, Buchanan  D.  Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial.   JAMA. 2009;301(17):1771-1778. doi:10.1001/jama.2009.561PubMedGoogle ScholarCrossref
    Shumway  M, Boccellari  A, O’Brien  K, Okin  RL.  Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial.   Am J Emerg Med. 2008;26(2):155-164. doi:10.1016/j.ajem.2007.04.021PubMedGoogle ScholarCrossref
    Shannon  GR, Wilber  KH, Allen  D.  Reductions in costly healthcare service utilization: findings from the Care Advocate Program.   J Am Geriatr Soc. 2006;54(7):1102-1107. doi:10.1111/j.1532-5415.2006.00799.xPubMedGoogle ScholarCrossref
    Buchanan  D, Doblin  B, Sai  T, Garcia  P.  The effects of respite care for homeless patients: a cohort study.   Am J Public Health. 2006;96(7):1278-1281. doi:10.2105/AJPH.2005.067850PubMedGoogle ScholarCrossref
    Becker  MG, Hall  JS, Ursic  CM, Jain  S, Calhoun  D.  Caught in the Crossfire: the effects of a peer-based intervention program for violently injured youth.   J Adolesc Health. 2004;34(3):177-183. doi:10.1016/S1054-139X(03)00278-7PubMedGoogle ScholarCrossref
    Pettignano  R, Caley  SB, McLaren  S.  The health law partnership: adding a lawyer to the health care team reduces system costs and improves provider satisfaction.   J Public Health Manag Pract. 2012;18(4):E1-E3. doi:10.1097/PHH.0b013e31823991a9PubMedGoogle ScholarCrossref
    Mares  AS, Rosenheck  RA.  Twelve-month client outcomes and service use in a multisite project for chronically homelessness adults.   J Behav Health Serv Res. 2010;37(2):167-183. doi:10.1007/s11414-009-9171-5PubMedGoogle ScholarCrossref
    Liss  DT, Ackermann  RT, Cooper  A,  et al.  Effects of a transitional care practice for a vulnerable population: a pragmatic, randomized comparative effectiveness trial.   J Gen Intern Med. 2019;34(9):1758-1765. doi:10.1007/s11606-019-05078-4PubMedGoogle ScholarCrossref
    Berkowitz  SA, Terranova  J, Randall  L, Cranston  K, Waters  DB, Hsu  J.  Association between receipt of a medically tailored meal program and health care use.   JAMA Intern Med. 2019;179(6):786-793. doi:10.1001/jamainternmed.2019.0198PubMedGoogle ScholarCrossref
    Srebnik  D, Connor  T, Sylla  L.  A pilot study of the impact of housing first–supported housing for intensive users of medical hospitalization and sobering services.   Am J Public Health. 2013;103(2):316-321. doi:10.2105/AJPH.2012.300867PubMedGoogle ScholarCrossref
    Sherratt  M, Jones  K, Middleton  P.  A citizens’ advice service in primary care: improving patient access to benefits.   Prim Health Care Res Dev. 2000;1(3):139-146. doi:10.1191/146342300672823063Google ScholarCrossref
    Bove  AM, Gough  ST, Hausmann  LRM.  Providing no-cost transport to patients in an underserved area: impact on access to physical therapy.   Physiother Theory Pract. 2019;35(7):645-650.PubMedGoogle Scholar
    Bovell-Ammon  A, Mansilla  C, Poblacion  A,  et al.  Housing intervention for medically complex families associated with improved family health: pilot randomized trial.   Health Aff (Millwood). 2020;39(4):613-621. doi:10.1377/hlthaff.2019.01569PubMedGoogle ScholarCrossref
    Freeman  AL, Li  T, Kaplan  SA,  et al.  Community health worker intervention in subsidized housing: New York City, 2016-2017.   Am J Public Health. 2020;110(5):689-692. doi:10.2105/AJPH.2019.305544PubMedGoogle ScholarCrossref
    Lindau  ST, Makelarski  JA, Abramsohn  EM,  et al.  CommunityRx: a real-world controlled clinical trial of a scalable, low-intensity community resource referral intervention.   Am J Public Health. 2019;109(4):600-606. doi:10.2105/AJPH.2018.304905PubMedGoogle ScholarCrossref
    Nguyen  KH, Trivedi  AN, Cole  MB.  Receipt of social needs assistance and health center patient experience of care.   Am J Prev Med. 2021;60(3):e139-e147. doi:10.1016/j.amepre.2020.08.030PubMedGoogle ScholarCrossref
    Smith  MA, Moyer  D.  Frequent user system engagement: a quality improvement project to examine outcomes of a partnership to improve the health of emergency department frequent users.   J Nurs Care Qual. 2020;23:23. doi:10.1097/01.NCQ.0000303802.30327.7fPubMedGoogle ScholarCrossref
    Wu  AW, Weston  CM, Ibe  CA,  et al.  The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) cluster RCT.   Am J Prev Med. 2019;57(2):e31-e41. doi:10.1016/j.amepre.2019.03.013PubMedGoogle ScholarCrossref
    Xiang  X, Zuverink  A, Rosenberg  W, Mahmoudi  E.  Social work-based transitional care intervention for super utilizers of medical care: a retrospective analysis of the bridge model for super utilizers.   Soc Work Health Care. 2019;58(1):126-141. doi:10.1080/00981389.2018.1547345PubMedGoogle ScholarCrossref
    Pinto  AD, Da Ponte  M, Bondy  M,  et al.  Addressing financial strain through a peer-to-peer intervention in primary care.   Fam Pract. 2020;37(6):815-820. doi:10.1093/fampra/cmaa046PubMedGoogle ScholarCrossref
    Whorms  DS, Narayan  AK, Pourvaziri  A,  et al.  Analysis of the effects of a patient-centered rideshare program on missed appointments and timeliness for MRI appointments at an academic medical center.   J Am Coll Radiol. 2021;18(2):240-247. doi:10.1016/j.jacr.2020.05.037PubMedGoogle ScholarCrossref
    Cullen  D, Blauch  A, Mirth  M, Fein  J.  Complete Eats: summer meals offered by the emergency department for food insecurity.   Pediatrics. 2019;144(4):e20190201. doi:10.1542/peds.2019-0201PubMedGoogle Scholar
    Moreno  G, Mangione  CM, Tseng  CH,  et al.  Connecting Provider to Home: a home-based social intervention program for older adults.   J Am Geriatr Soc. 2021;69(6):1627-1637. doi:10.1111/jgs.17071PubMedGoogle ScholarCrossref
    Rosen Valverde  JN, Backstrand  J, Hills  L, Tanuos  H.  Medical-legal partnership impact on parents’ perceived stress: a pilot study.   Behav Med. 2019;45(1):70-77. doi:10.1080/08964289.2018.1481011PubMedGoogle ScholarCrossref
    Cullen  D, Woodford  A, Fein  J.  Food for Thought: a randomized trial of food insecurity screening in the emergency department.   Acad Pediatr. 2019;19(6):646-651. doi:10.1016/j.acap.2018.11.014PubMedGoogle ScholarCrossref
    Kwon  SC, Trinh-Shevrin  C, Wauchope  K,  et al.  Innovations in payer-community partnerships: the EmblemHealth neighborhood care program.   Int Q Community Health Educ. 2017;38(1):57-64. doi:10.1177/0272684X17740694PubMedGoogle ScholarCrossref
    Sundar  KR.  Universal screening for social needs in a primary care clinic: a quality improvement approach using the Your Current Life Situation survey.   Perm J. 2018;22:18-089. doi:10.7812/TPP/18-089PubMedGoogle Scholar
    Gottlieb  LM, Wing  H, Adler  NE.  A systematic review of interventions on patients’ social and economic needs.   Am J Prev Med. 2017;53(5):719-729. doi:10.1016/j.amepre.2017.05.011PubMedGoogle ScholarCrossref
    Wolff  TA, Krist  AH, LeFevre  M,  et al.  Update on the methods of the U.S. Preventive Services Task Force: linking intermediate outcomes and health outcomes in prevention.   Am J Prev Med. 2018;54(1 suppl 1):S4-S10. doi:10.1016/j.amepre.2017.08.032PubMedGoogle ScholarCrossref
    Tsai  J, Gelberg  L, Rosenheck  RA.  Changes in physical health after supported housing: results from the collaborative initiative to end chronic homelessness.   J Gen Intern Med. 2019;34(9):1703-1708. doi:10.1007/s11606-019-05070-yPubMedGoogle ScholarCrossref
    Tong  ST, Liaw  WR, Kashiri  PL,  et al.  Clinician experiences with screening for social needs in primary care.   J Am Board Fam Med. 2018;31(3):351-363. doi:10.3122/jabfm.2018.03.170419PubMedGoogle ScholarCrossref
    Thomas-Henkel  C, Schulman  M. Screening for social determinants of health in populations with complex needs: implementation considerations. Center for Health Care Strategies. Updated October 2017. Accessed December 2, 2019.
    National Academies of Sciences, Engineering, and Medicine.  Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. National Academies Press; 2019.
    Garg  A, Homer  CJ, Dworkin  PH.  Addressing social determinants of health: challenges and opportunities in a value-based model.   Pediatrics. 2019;143(4):e20182355. doi:10.1542/peds.2018-2355PubMedGoogle Scholar
    Orr  CJ, Chauvenet  C, Ozgun  H, Pamanes-Duran  C, Flower  KB.  Caregivers’ experiences with food insecurity screening and impact of food insecurity resources.   Clin Pediatr (Phila). 2019;58(14):1484-1492. doi:10.1177/0009922819850483PubMedGoogle ScholarCrossref
    Mor  K, Hobor  G, Riccardo  J, Robinson  M.  From Theory to practice: a 2-year demonstration of the Community-Centered Health Home model.   J Public Health Manag Pract. 2017;23(suppl 6 suppl, Gulf Region Health Outreach Program):S47-S53. doi:10.1097/PHH.0000000000000651PubMedGoogle ScholarCrossref
    Andermann  A.  Screening for social determinants of health in clinical care: moving from the margins to the mainstream.   Public Health Rev. 2018;39:19. doi:10.1186/s40985-018-0094-7PubMedGoogle ScholarCrossref
    Alderwick  HAJ, Gottlieb  LM, Fichtenberg  CM, Adler  NE.  Social prescribing in the U.S. and England: emerging interventions to address patients’ social needs.   Am J Prev Med. 2018;54(5):715-718. doi:10.1016/j.amepre.2018.01.039PubMedGoogle ScholarCrossref
    Byhoff  E, Garg  A, Pellicer  M,  et al.  Provider and staff feedback on screening for social and behavioral determinants of health for pediatric patients.   J Am Board Fam Med. 2019;32(3):297-306. doi:10.3122/jabfm.2019.03.180276PubMedGoogle ScholarCrossref
    LaForge  K, Gold  R, Cottrell  E,  et al.  How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview.   J Ambul Care Manage. 2018;41(1):2-14. doi:10.1097/JAC.0000000000000221PubMedGoogle ScholarCrossref
    O’Gurek  DT, Henke  C.  A practical approach to screening for social determinants of health.   Fam Pract Manag. 2018;25(3):7-12.PubMedGoogle Scholar
    Gold  R, Cottrell  E, Bunce  A,  et al.  Developing electronic health record (EHR) strategies related to health center patients’ social determinants of health.   J Am Board Fam Med. 2017;30(4):428-447. doi:10.3122/jabfm.2017.04.170046PubMedGoogle ScholarCrossref
    Pooler  JA, Hoffman  VA, Karva  FJ.  Primary care providers’ perspectives on screening older adult patients for food insecurity.   J Aging Soc Policy. 2018;30(1):1-23. doi:10.1080/08959420.2017.1363577PubMedGoogle ScholarCrossref
    Alley  DE, Asomugha  CN, Conway  PH, Sanghavi  DM.  Accountable health communities—addressing social needs through Medicare and Medicaid.   N Engl J Med. 2016;374(1):8-11. doi:10.1056/NEJMp1512532PubMedGoogle ScholarCrossref
    Amarashingham  R, Xie  B, Karam  A, Nguyen  N, Kapoor  B.  Using community partnerships to integrate health and social services for high-need, high-cost patients.   Issue Brief (Commonw Fund). 2018;2018:1-11.PubMedGoogle Scholar
    Barnidge  E, Stenmark  S, Seligman  H.  Clinic-to-community models to address food insecurity.   JAMA Pediatr. 2017;171(6):507-508. doi:10.1001/jamapediatrics.2017.0067PubMedGoogle ScholarCrossref
    Lavoie  JG, Varcoe  C, Wathen  CN, Ford-Gilboe  M, Browne  AJ; EQUIP Research Team.  Sentinels of inequity: examining policy requirements for equity-oriented primary healthcare.   BMC Health Serv Res. 2018;18(1):705. doi:10.1186/s12913-018-3501-3PubMedGoogle ScholarCrossref
    Lundeen  EA, Siegel  KR, Calhoun  H,  et al.  Clinical-community partnerships to identify patients with food insecurity and address food needs.   Prev Chronic Dis. 2017;14:E113. doi:10.5888/pcd14.170343PubMedGoogle Scholar
    Byhoff  E, De Marchis  EH, Hessler  D,  et al.  Part II: a qualitative study of social risk screening acceptability in patients and caregivers.   Am J Prev Med. 2019;57(6)(suppl 1):S38-S46. doi:10.1016/j.amepre.2019.07.016PubMedGoogle ScholarCrossref
    Chhabra  M, Sorrentino  AE, Cusack  M, Dichter  ME, Montgomery  AE, True  G.  Screening for housing instability: providers’ reflections on addressing a social determinant of health.   J Gen Intern Med. 2019;34(7):1213-1219. doi:10.1007/s11606-019-04895-xPubMedGoogle ScholarCrossref
    Colvin  JD, Bettenhausen  JL, Anderson-Carpenter  KD, Collie-Akers  V, Chung  PJ.  Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents.   Acad Pediatr. 2016;16(2):161-167. doi:10.1016/j.acap.2015.06.002PubMedGoogle ScholarCrossref
    Cullen  D, Attridge  M, Fein  JA.  Food for Thought: a qualitative evaluation of caregiver preferences for food insecurity screening and resource referral.   Acad Pediatr. 2020;20(8):1157-1162. doi:10.1016/j.acap.2020.04.006PubMedGoogle ScholarCrossref
    De Marchis  EH, Hessler  D, Fichtenberg  C,  et al.  Part I: a quantitative study of social risk screening acceptability in patients and caregivers.   Am J Prev Med. 2019;57(6)(suppl 1):S25-S37. doi:10.1016/j.amepre.2019.07.010PubMedGoogle ScholarCrossref
    Ettinger de Cuba  S, Chilton  M, Bovell-Ammon  A,  et al.  Loss of SNAP is associated with food insecurity and poor health in working families with young children.   Health Aff (Millwood). 2019;38(5):765-773. doi:10.1377/hlthaff.2018.05265PubMedGoogle ScholarCrossref
    Fleegler  EW, Lieu  TA, Wise  PH, Muret-Wagstaff  S.  Families’ health-related social problems and missed referral opportunities.   Pediatrics. 2007;119(6):e1332-e1341. doi:10.1542/peds.2006-1505PubMedGoogle ScholarCrossref
    Galvin  K, Sharples  A, Jackson  D.  Citizens Advice Bureaux in general practice: an illuminative evaluation.   Health Soc Care Community. 2000;8(4):277-282. doi:10.1046/j.1365-2524.2000.00249.xPubMedGoogle ScholarCrossref
    Greasley  P, Small  N.  Establishing a welfare advice service in family practices: views of advice workers and primary care staff.   Fam Pract. 2005;22(5):513-519. doi:10.1093/fampra/cmi047PubMedGoogle ScholarCrossref
    Hamity  C, Jackson  A, Peralta  L, Bellows  J.  Perceptions and experience of patients, staff, and clinicians with social needs assessment.   Perm J. 2018;22:18-105.PubMedGoogle Scholar
    Jaganath  D, Johnson  K, Tschudy  MM, Topel  K, Stackhouse  B, Solomon  BS.  Desirability of clinic-based financial services in urban pediatric primary care.   J Pediatr. 2018;202:285-290. doi:10.1016/j.jpeds.2018.05.055PubMedGoogle ScholarCrossref
    O’Toole  TP, Roberts  CB, Johnson  EE.  Screening for food insecurity in six Veterans Administration clinics for the homeless, June-December 2015.   Prev Chronic Dis. 2017;14:E04. doi:10.5888/pcd14.160375PubMedGoogle Scholar
    Pinto  AD, Bondy  M, Rucchetto  A, Ihnat  J, Kaufman  A.  Screening for poverty and intervening in a primary care setting: an acceptability and feasibility study.   Fam Pract. 2019;36(5):634-638. doi:10.1093/fampra/cmy129PubMedGoogle ScholarCrossref
    Quinn  C, Johnson  K, Raney  C,  et al.  “In the Clinic They Know Us”: preferences for clinic-based financial and employment services in urban pediatric primary care.   Acad Pediatr. 2018;18(8):912-919. doi:10.1016/j.acap.2018.06.008PubMedGoogle ScholarCrossref
    Saxe-Custack  A, Lofton  HC, Hanna-Attisha  M,  et al.  Caregiver perceptions of a fruit and vegetable prescription programme for low-income paediatric patients.   Public Health Nutr. 2018;21(13):2497-2506. doi:10.1017/S1368980018000964PubMedGoogle ScholarCrossref
    Schickedanz  A, Hamity  C, Rogers  A, Sharp  AL, Jackson  A.  Clinician experiences and attitudes regarding screening for social determinants of health in a large integrated health system.   Med Care. 2019;57(suppl 6 suppl 2):S197-S201. doi:10.1097/MLR.0000000000001051PubMedGoogle ScholarCrossref
    Williams  BC, Ward  DA, Chick  DA, Johnson  EL, Ross  PT.  Using a six-domain framework to include biopsychosocial information in the standard medical history.   Teach Learn Med. 2019;31(1):87-98. doi:10.1080/10401334.2018.1480958PubMedGoogle ScholarCrossref
    Garg  A, Sheldrick  RC, Dworkin  PH.  The inherent fallibility of validated screening tools for social determinants of health.   Acad Pediatr. 2018;18(2):123-124. doi:10.1016/j.acap.2017.12.006PubMedGoogle ScholarCrossref