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32 l Nursing2022 l Volume 52, Number 4 www.Nursing2022.com

BY VICTORIA TIASE, MSN, RN-BC; CATHRYN DEGRAFF CROOKSTON, BSN, RN;
ANNA SCHOENBAUM, DNP, MS, RN-BC; AND MADELYNN VALU, MPH, RD

Nurses’ role in addressing social
determinants of health

fying and helping patients manage
these social determinants of health
(SDOH) should be key parts of
proactive patient care. In the past,
data about SDOH were either un-
known or had fallen outside of the
traditional purview of hospitals and
clinics.2 To collect and exchange
SDOH information, methods were
developed to screen and collect
data electronically. In 2014, the
National Academy of Medicine cre-
ated standard social and behavioral
domains for primary care settings
highlighting the importance of
capturing these domains electroni-

cally.2 This involves implementing
tools to support SDOH assessment
by healthcare teams and standard-
izing the process for conducting
SDOH assessments within roles and
responsibilities.

Multiple national medical profes-
sional associations recommend social
risk screening and documentation
in healthcare settings because of the
compelling evidence that social risks
are associated with poorer adherence
to treatment plans, worse health out-
comes, and increased costs of care.3
Despite these recommendations and
growing national attention for the

PA
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Abstract: Nurses have a vital role in ad-
dressing social and health inequities to
promote quality healthcare for all. This ar-
ticle discusses the tools to screen for social
determinants of health (SDOH) and key
considerations for nurses and nurse leaders
to advance the integration of SDOH infor-
mation into their workflows.

Keywords: SDOH, social determinants of
health, health disparities, health equity

Up to 80% of a person’s health is
determined by socioeconomic fac-
tors, health-related behaviors, and
environmental conditions.1 Identi-

OPEN

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www.Nursing2022.com April l Nursing2022 l 33

health impacts of SDOH, the uptake
and prevalence of healthcare-based
screening for service delivery are
highly variable, and existing efforts
to assess patients’ SDOH have typi-
cally been ad hoc.4

The Centers for Medicare and
Medicaid Services developed the
Accountable Health Communities
(AHC) Health-Related Social Needs
(HRSN) Screening Tool to address
the critical gap between clinical
care and community services.5 This
unique 10-question tool assesses five
key domains of health-related social
needs, collecting a breadth of infor-
mation that increases the likelihood
of identifying significant needs.5,6

The tool can also be integrated into
multiple clinical workflows and ac-
cessible across diverse patient popu-
lations.6

In a study evaluating the accept-
ability of the AHC HRSN Screening
Tool among adult patients and adult
caregivers of pediatric patients,
a sizable majority of participants
found the tool appropriate across di-
verse healthcare settings.7 They also
reported being comfortable with
having the results integrated into
electronic health record (EHR) sys-
tems.7 Screening acceptability varied
among subgroups based on prior
exposure to social screening and
assistance, trust in clinicians, experi-
ence with healthcare discrimination,
and recruitment from a primary care
setting or healthcare facility with
more patients who are uninsured or
have public health insurance. These
variations were small to moderate,
and both screening appropriateness
and comfort with EHR documenta-
tion were high for all subgroups.
These findings suggest that patient
acceptability is not likely a major
barrier to SDOH screening imple-
mentation.7 Given these findings,
barriers could be more closely as-
sociated with technical and logisti-
cal factors such as workflow, data
collection, review and response,

screening tool implementation, and
referral mechanisms. Additionally,
the United States is in the midst of a
deeply problematic nursing shortage
that is expected to continue through
2030.8 This has created a major
imbalance in workloads for those
remaining in the job and resulted in
less time, incomplete communica-
tion, and thus, lapses in continuity
of care.9

This article reviews the SDOH
assessment process and screening
tools used in the context of nursing
workflows and discusses key consid-
erations for nurses and nurse leaders
to advance the integration of SDOH
information into clinical care.

Screening tools
SDOH assessment tools are used to
identify social risks that reflect a per-
son’s unmet social needs. Although
differing in methodology, content,
and follow-up procedures, these
tools often focus on key SDOH do-
mains.10 These commonly include
housing, food, transportation, em-
ployment, education, financial strain,
and personal safety.11

Although an organization could
develop and validate its own ques-
tions, organizations often find it most
expedient to implement existing and
validated assessment questions or
tools. Many SDOH screening tools
are available.11-14 However, there is a
lack of national guidance on the use
and effectiveness of these tools (see
Common SDOH screening tools).15 Ac-
cording to the National Committee
for Quality Assurance (NCQA) Social
Determinants of Health Resource
Guide, organizations must make ad-
dressing SDOH a strategic priority
then design an SDOH assessment
program involving these four main
workstreams:16

• Whom to assess: Determining
whom to assess might depend on
an organization’s resources, bud-
get, and current workflows. Some
organizations begin with universal

assessments, while others start with
high-risk individuals and expand to
a broader scope once workflows are
optimized.
• What to assess: There are three dif-
ferent approaches to SDOH assess-
ment. Strengths-based assessment is
often used in behavioral health and
focuses on measuring a person’s pro-
tective factors (such as social support
system, access to resources) that help
them thrive in adversity. Risk-based
assessment and needs-based assess-
ment are commonly used in medical
environments. They focus on captur-
ing individual characteristics that put
a person at risk for poorer physical
health (such as poverty, sexual orien-
tation) or an individual’s immediate
unmet social needs.
• What questions to ask: Although
most readily available SDOH as-
sessment tools include screening
questions on food, housing, trans-
portation, and finances, limited
evidence supports screening for spe-
cific SDOH factors. When choosing
specific questions, consider the social
risks in the population served and
available local resources.
• How to implement the assessment:
A variety of individuals may have
responsibility for SDOH assessment
including social workers, commu-
nity health workers, physicians, care
managers, nurses, transportation pro-
viders, clergy, housing assistance pro-
viders, and other service providers.
Methods used for collecting informa-
tion have included verbal in-person,
verbal remote, written assessment,
and through a kiosk, computer work-
station, smartphone, or tablet.

Research on the effectiveness
of screening in improving patient
outcomes has been divided into
two categories: (1) screening for
single domains of social risk and
(2) simultaneously screening for
multiple domains of social risk.17
Given that social risks tend to aggre-
gate, screening for multiple SDOH
domains would seem to make more

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34 l Nursing2022 l Volume 52, Number 4 www.Nursing2022.com

sense; however, there is a much
larger body of research related to
screening for single domains of so-
cial risk, particularly intimate part-
ner violence, suicide, and child and
elder abuse.18 A 2017-18 National
Survey of Healthcare Organiza-
tions and Systems that estimated
the prevalence of screening for five
social risks (food insecurity, hous-
ing instability, utility needs, trans-
portation needs, and interpersonal
violence) concluded that screening
across multiple domains is not yet
common in clinical settings.19

Once an organization has decided
to screen, the fourth workstream

becomes critical: How to implement
the assessment. Although many
community-based organizations may
initiate assessments or the patients
themselves may choose to complete
a digital screening tool, this article
focuses on healthcare organizations
as the point of origin of assessments.

Working in the most trusted pro-
fession, as reported in the most recent
Gallup Honesty and Ethics poll,
nurses are in a unique position to
screen for SDOH.20 One study found
that nurses feel knowledgeable and
confident in discussing certain deter-
minants of health, particularly issues
related to access to healthcare.21 With

an integrated screening tool acces-
sible from the EHR, nurses can collect
SDOH data within their current docu-
mentation workflows. Having this in-
formation can be valuable to support
patient care and discharge processes.
All aspects—including confidence in
discussing SDOH, knowledge about
the importance of collecting this in-
formation, and proficiency in using
an integrated screen tool—must be
addressed with nursing workflows in
mind to increase adoption and use.

The SDOH screening expectations
and frequency should be outlined in
the organization’s standard processes
(for example, during triage or intake,

Common SDOH screening tools
Screening Tool Developed By Features

Protocol for Responding
to and Assessing Patient’s
Assets, Risks and Experiences
(PRAPARE)

National Association of
Community Health Centers
(NACHC)

Consists of a set of national core measures and a set
of optional measures for community priorities

Informed by research, the experience of existing so-
cial risk assessments, and stakeholder engagement

Aligns with national initiatives prioritizing social de-
terminants (such as Healthy People 2030), measures
proposed under the next stage of Meaningful Use,
clinical coding under ICD-10, and health centers’
Uniform Data System11

Health-Related Social Needs
(HRSN)

Centers for Medicare and Medicaid
Services (CMS)

Developed as part of the Accountable Health Com-
munities Model to determine if systematic screening
for health-related social needs affects total healthcare
costs and health outcomes

Helps providers find patients’ needs in five core do-
mains including housing instability, food insecurity,
transportation problems, utility help needs, and inter-
personal safety4

The Health Leads Social Needs
Screening Toolkit

Health Leads Provides a comprehensive blueprint for organizations
seeking to identify and screen individuals for adverse
social determinants of health

Includes updates based on the latest social needs
research, lessons learned from long-standing screen-
ing programs, and feedback from clinicians and
healthcare providers12

HealthBegins HealthBegins Contains 28 questions assessing five domains: eco-
nomic stability, education, social and community
context, neighborhood and physical environment,
and food13

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www.Nursing2022.com April l Nursing2022 l 35

prior or after the initial appointment,
at discharge, and on every home
visit) and part of nursing orientation
processes. The frequency of SDOH
screening must be clearly outlined,
noting that it may be adjusted ac-
cording to the patient’s risk level and
ongoing needs. As SDOH data are
modified over time, the creation of
an electronic notification within the
EHR would be beneficial to alert care
team members when new data are
present. Procedures for successful
screening should consider patient
education on the reasons for collect-
ing data, how it will be used, and
who will have access to the data.

Access to and integration of
SDOH data
Using collected SDOH data, nurses
will have the ability to identify
patients at risk for negative health
outcomes and connect patients with
needed services. Based on the socio-
economic and environmental needs
and risks of the patient, SDOH data
can be reviewed regularly along-
side the plan of care to address the
patient’s needs. Easy access to and
visibility of SDOH data facilitates
referrals to community services and
supports a greater understanding of
the factors that affect health.

Information overload has been a
critical issue for clinicians, who often
have limited time to review the vast
amount of data that has not been
translated into relevant informa-
tion when they are needed.22 The
collection and documentation of
the information itself also increases
responsibility and workload of
nurses, who are often tasked with
administrative burdens that would
otherwise be outside of their job de-
scriptions.23,24 Accessing information
at the proper point in the clinical
decision-making process is critical.25
To optimize its use, SDOH data must
be integrated into clinical workflows
in a way that supports the efficient
use of the information without creat-

ing an undue burden on nurses.
Common approaches to imple-

menting clinical decision support
tools, such as identifying the needs
of the users and what the system is
expected to do, may be useful in inte-
grating SDOH data into workflows.26

This includes the use of the EHR in
presenting the right data in the right
place to the right clinician at the cor-
rect point of the clinical workflow.27

A thorough understanding of SDOH
information needs in settings and
situations may also contribute to its
optimal integration into workflows.

To decrease the cognitive burden
of nurses, machine learning algo-
rithms can be used to build SDOH
data models. These types of predic-
tive and prescriptive analytics can
provide new insights into the interac-
tion between social conditions and
health outcomes in specific patient
populations. A recent study in the
American Journal of Managed Care
found that applied machine learning

can be used to predict patient utiliza-
tion of inpatient and EDs based on
their SDOH.28 These findings can be
applied on a wider scale and could
positively impact patients, the com-
munity, and the health systems.28

Interoperability
Nurses must also explore the level
of interoperability or the amount
of SDOH data exchange between
healthcare organizations and external
stakeholders, particularly its impact on
nursing workflows. It is important that
SDOH data can be shared and ex-
changed with community partners and
other healthcare systems to develop a
system of holistic and longitudinal care
for patients, primary care providers,
case managers, and other healthcare
workers who may require access to
SDOH data. Data flows should be
examined, and where possible, SDOH
data should be reused and shared for
optimal use (see SDOH screening in
clinical practice: Use cases).29

SDOH screening in clinical practice: Use cases
Use case #1: Primary care clinic care setting
Prisma Health in Greenville, S.C., implemented SDOH screening tools in a
phased approach for their value-based contract patients and uninsured patients
in the primary care clinics. During the intake process, nurse care managers con-
duct a basic needs SDOH screening in the EHR. Next, the nurse care manager
generates a list of personalized referrals via a referral platform embedded in the
EHR. The referral list is attached to the After Visit Summary and shared with the
patient in their preferred modality (text, email, or print). Prisma Health plans to
roll out this process within all ambulatory clinics across their enterprise to screen
all patients in support of their health for SDOH impact.

Use case #2: Primary care and inpatient care settings
Allina Health, based in Minneapolis, Minn., utilizes the Accountable Health Com-
munities (AHC) Model. During the intake process in the primary care clinics, all
patients with Medicare and Medicaid are screened using the AHC screening tool.
With the standardization of this process, Allina Health has been able to reach 90%
of its target population screening goal along with community referrals. Patients with
identified established needs receive a consult for nurse navigation. Allina Health
has found that patients with existing primary care are most interested in accept-
ing navigation services, highlighting the importance of establishing a primary care
relationship that enables trust for the provision of services such as care navigation.

Allina Health also utilizes the AHC screening tool in the inpatient units, focusing
on the behavioral health and population of mothers and babies. Incorporating
the tool into their workflow, nurses screen, identify, and “e-prescribe” personal-
ized referrals based on SDOH needs and available community services.

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36 l Nursing2022 l Volume 52, Number 4 www.Nursing2022.com

Recommendations for nurses
Although nurses routinely consider
the elements of SDOH in clinical
practice, the systematic collection
and established procedures for use
are not commonplace in healthcare
organizations.30 Nurses can take the
lead in education, research, and prac-
tice by partnering with community
organizations. Nurse leaders should
participate in organizations, task
forces, and committees at the local,
state, or national level to advance
standards, policies, and incentives
supporting the collection, use, and
sharing of SDOH data.31 Nurses can
cultivate a culture that promotes the
importance of SDOH among health-
care professionals and the integration
of screening tools and visualization of
SDOH data into existing workflows.
Finally, nurses must collaborate with
community agencies and healthcare
entities to define how SDOH can be
fully integrated into patient care (see
Steps to address SDOH).

For clinical nurses who want to
understand how SDOH data can
be integrated into their healthcare
organization, consider the following
actions:
• Learn more about the organization-
al policies and procedures for SDOH.

• Explore EHR documentation to
identify where SDOH data may al-
ready be collected and the best loca-
tions to review data.
• Encourage colleagues to have dis-
cussions with patients to understand
their comfort levels with sharing
SDOH information.
• Support and advise organizational
plans to implement SDOH into nurs-
ing workflows.
• Identify opportunities to conduct
a nursing inquiry for SDOH inter-
ventions.
• Establish ways to triage support
based on individual responses to
SDOH-related questions by involv-
ing interdisciplinary team members
such as social services, nutritionists,
and mental health professionals.

Conclusion
Integrating SDOH data into nursing
workflows has the potential to im-
prove patient care. Nurses are well-
positioned to advance operational ef-
forts to incorporate SDOH screening
tools and information into new care
models that prioritize the efficient use
and exchange of such information to
adequately meet patient needs. The
increased involvement of nurses and
nurse leaders in the use of social risk

data in clinical decision-making can
facilitate progress toward achieving
health equity for all. ■

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Steps to address SDOH

STEPS

Coordinate interdisciplinary education
and awareness of SDOH in practice

Explore new care models for the
collection of SDOH data

Research evidence-based practice
interventions using SDOH

Nurse leaders to take
actions to address

SDOH

Partner with community organizations
in addressing patient needs

Advance collection, use, and sharing
of SDOH data

NSG0422_SDOH_Ramakant.indd 36 29/04/22 7:07 PM

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

www.Nursing2022.com April l Nursing2022 l 37

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29. Cantor MN, Thorpe L. Integrating data on
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Victoria Tiase is the director of Informatics Strategy
at New York-Presbyterian Hospital. Cathryn DeGraff
Crookston is the senior director for Provider Sales
Solutions at Unite Us. Anna Schoenbaum is the
vice-president of Information Services Applications
at Penn Medicine and a faculty at the University of
Maryland School of Nursing. Madelynn Valu is the
senior manager of Public Health at Circulo Health.
All authors are members of the Healthcare Infor-
mation and Management Systems Society’s Social
Determinants of Health Task Force, with Ms. DeGraff
Crookston as a co-chair.

Copyright © 2022 The Author. Published by Wolters
Kluwer Health, Inc. This is an open access article
distributed under the terms of the Creative Commons
Attribution Non Commercial-No Derivatives License
4.0 (CCBY-NC-ND), where it is permissible to down-
load and share the work provided it is properly cited.
The work cannot be changed in any way or used
commercially without permission from the journal.

The authors have disclosed no financial relationships
related to this article.

DOI-10.1097/01.NURSE.0000823284.16666.96

NSG0422_SDOH_Ramakant.indd 37 29/04/22 7:07 PM

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