Social risk factors, the social determinants of health associated with negative health outcomes, drive patient-level social needs that contribute to health inequalities, high medical cost, overutilization of services, and have a greater impact on morbidity, mortality, and quality of life than chronic diseases (Krist et al., 2020). While there seems to be a consensus on the importance of addressing social factors, most health systems lack the infrastructure to develop the screening and referral protocols required to address social needs (Alley et al., 2020). Primary care has been identified as a key setting to introduce strategies around identifying at-risk patients with social needs and linking them to community resources as they are typically the first point of health care access for most people (Valaitis et al., 2020). The goal of this project was to develop screening processes and workflows in primary care settings to connect patients to community resources using care navigational resources. A 10-week pilot was conducted at two practices. The implementation of screening tools, workflows, and referrals pathways were evaluated to understand the model’s impact on care delivery and to make recommendations for scaling the processes to other practice sites. A total of 150 patients were screened, and 71 patients reported to having at least one social need. The importance of addressing social needs within insured populations was highlighted with nearly half of the patients screening positive. Providers were surveyed post-implementation using a five-point Likert scale questionnaire. They expressed positive overall feelings about the process. The project supports that integrating social factors into the provision of care moves practices towards the realization of whole-person care for the promotion of health and wellbeing
","abstract_html":"<p>Social risk factors, the social determinants of health associated with negative health outcomes, drive patient-level social needs that contribute to health inequalities, high medical cost, overutilization of services, and have a greater impact on morbidity, mortality, and quality of life than chronic diseases (Krist et al., 2020). While there seems to be a consensus on the importance of addressing social factors, most health systems lack the infrastructure to develop the screening and referral protocols required to address social needs (Alley et al., 2020). Primary care has been identified as a key setting to introduce strategies around identifying at-risk patients with social needs and linking them to community resources as they are typically the first point of health care access for most people (Valaitis et al., 2020). The goal of this project was to develop screening processes and workflows in primary care settings to connect patients to community resources using care navigational resources. A 10-week pilot was conducted at two practices. The implementation of screening tools, workflows, and referrals pathways were evaluated to understand the model’s impact on care delivery and to make recommendations for scaling the processes to other practice sites. A total of 150 patients were screened, and 71 patients reported to having at least one social need. The importance of addressing social needs within insured populations was highlighted with nearly half of the patients screening positive. Providers were surveyed post-implementation using a five-point Likert scale questionnaire. They expressed positive overall feelings about the process. The project supports that integrating social factors into the provision of care moves practices towards the realization of whole-person care for the promotion of health and wellbeing</p>","abstract_has_math":false,"creators":["Matthews, Mindy Marie"],"institution":null,"degree_name":"Doctor of Nursing Practice (DNP)","degree_level":"Open Access Thesis","degree_discipline":"Yale University School of Nursing","degree_department":null,"school":null,"contributors":["Mary Ann Camilleri"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2023,"date_issued":"2023-01-01T08:00:00Z","date_published":"2023-01-01T08:00:00Z","updated_at":"2026-07-24T06:16:14Z","subjects":["Social Determinants of Health, Social Needs"],"languages":[],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://elischolar.library.yale.edu/ysndt/1158","outbound_label":"Repository record","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["Mary Ann Camilleri"]},{"key":"dc:creator","label":"Author","values":["Matthews, Mindy Marie"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"thesis:degree_discipline","label":"Discipline","values":["Yale University School of Nursing"]},{"key":"thesis:degree_level","label":"Degree Level","values":["Open Access Thesis"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Doctor of Nursing Practice (DNP)"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Social Determinants of Health, Social Needs"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://elischolar.library.yale.edu/ysndt/1158"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["Social risk factors, the social determinants of health associated with negative health outcomes, drive patient-level social needs that contribute to health inequalities, high medical cost, overutilization of services, and have a greater impact on morbidity, mortality, and quality of life than chronic diseases (Krist et al., 2020). While there seems to be a consensus on the importance of addressing social factors, most health systems lack the infrastructure to develop the screening and referral protocols required to address social needs (Alley et al., 2020). Primary care has been identified as a key setting to introduce strategies around identifying at-risk patients with social needs and linking them to community resources as they are typically the first point of health care access for most people (Valaitis et al., 2020). The goal of this project was to develop screening processes and workflows in primary care settings to connect patients to community resources using care navigational resources. A 10-week pilot was conducted at two practices. The implementation of screening tools, workflows, and referrals pathways were evaluated to understand the model’s impact on care delivery and to make recommendations for scaling the processes to other practice sites. A total of 150 patients were screened, and 71 patients reported to having at least one social need. The importance of addressing social needs within insured populations was highlighted with nearly half of the patients screening positive. Providers were surveyed post-implementation using a five-point Likert scale questionnaire. They expressed positive overall feelings about the process. The project supports that integrating social factors into the provision of care moves practices towards the realization of whole-person care for the promotion of health and wellbeing
"]},{"key":"dc:title","label":"Title","values":["Addressing Social Needs And Creating Community Linkage Pathways For Vulnerable Populations In Primary Care Practice Settings"]}]}],"canonical_facts":{"dc:contributor":["Mary Ann Camilleri"],"dc:creator":["Matthews, Mindy Marie"],"dc:description.abstract":["Social risk factors, the social determinants of health associated with negative health outcomes, drive patient-level social needs that contribute to health inequalities, high medical cost, overutilization of services, and have a greater impact on morbidity, mortality, and quality of life than chronic diseases (Krist et al., 2020). While there seems to be a consensus on the importance of addressing social factors, most health systems lack the infrastructure to develop the screening and referral protocols required to address social needs (Alley et al., 2020). Primary care has been identified as a key setting to introduce strategies around identifying at-risk patients with social needs and linking them to community resources as they are typically the first point of health care access for most people (Valaitis et al., 2020). The goal of this project was to develop screening processes and workflows in primary care settings to connect patients to community resources using care navigational resources. A 10-week pilot was conducted at two practices. The implementation of screening tools, workflows, and referrals pathways were evaluated to understand the model’s impact on care delivery and to make recommendations for scaling the processes to other practice sites. A total of 150 patients were screened, and 71 patients reported to having at least one social need. The importance of addressing social needs within insured populations was highlighted with nearly half of the patients screening positive. Providers were surveyed post-implementation using a five-point Likert scale questionnaire. They expressed positive overall feelings about the process. The project supports that integrating social factors into the provision of care moves practices towards the realization of whole-person care for the promotion of health and wellbeing
"],"dc:identifier":["https://elischolar.library.yale.edu/ysndt/1158"],"dc:subject":["Social Determinants of Health, Social Needs"],"dc:title":["Addressing Social Needs And Creating Community Linkage Pathways For Vulnerable Populations In Primary Care Practice Settings"],"thesis:degree_discipline":["Yale University School of Nursing"],"thesis:degree_level":["Open Access Thesis"],"thesis:degree_name":["Doctor of Nursing Practice (DNP)"]},"updated_at":"2026-07-24T06:16:14Z"}