Abstract
Background: Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing the deleterious effects on patients’ health outcomes. Evidence is needed regarding approaches to implementing such screening in routine clinical encounters to enhance social care integration. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices.Methods: Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from providers and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients (n = 2,192) who received the PRAPARE as a standard of care at three of the center’s clinics (Adult Medicine, Family Medicine, and Pediatrics) were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. We used HEIF domains to inform a directed content analysis.Results: Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple levels (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach.Conclusion: Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care. Our findings highlight the dynamic relationship between barriers and facilitators to implementation at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.
Negotiating uncertainty in clinical encounters: A narrative exploration of naturally occurring primary care consultations
