Faculty, Staff and Student Publications

Language

English

Publication Date

4-6-2025

Journal

Health Services Research

DOI

10.1111/1475-6773.14516

PMCID

PMC11972723

PubMedCentral® Posted Date

4-6-2025

PubMedCentral® Full Text Version

Post-print

Abstract

Background: While healthcare screening for social determinants of health (SDOH) is increasing, not every patient who screens positive receives a referral to care coordination (community health workers, social workers, or case managers). Additionally, the impact of referral on patients' repeat screening is unknown.

Objective: The study aims to identify specific domains of SDOH that are associated with referrals to care coordination and assess the outcome of patients re–screened for SDOH at routine pediatric visits within 1 year. Additionally, this study aims to compare the SDOH needs identified on the initial and repeat screen.

Methods: The population includes patients who screened positive on a SDOH screener at a pediatric primary care clinic between August–December of 2022. The electronic medical record was retrospectively reviewed. Statistical analysis included logistic regression, Chi–square tests for referral groups, and McNemar tests for repeat screens.

Results: Of 420 patients who screened positive on the SDOH screener, 217 (51.7%) received referral to care coordination. Patients who screened positive for legal issues were more likely to receive a referral (p < 0.001). 227/420 (54%) patients were rescreened within the following year. Of these, 57.3% demonstrated no further needs, 18.1% demonstrated decreased needs, 19.8% demonstrated no change from the initial screen, and 4.8% demonstrated increased needs. There was a statistically significant difference in improvement between patients with and without referrals (p = 0.011). Overall, patients in both groups were likely to improve on the domains of food insecurity, financial strain, housing instability, and legal issues (p < 0.001). However, only the patients with a referral were likely to improve on the domain of health literacy (p < 0.001).

Conclusion: Most patients endorsed resolution or improvement of SDOH needs on repeat screen regardless of referral to care coordination, although patients who received referral were more likely to have improvement overall and of health literacy.

Published Open-Access

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