Background Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients’ health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response. Methods Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians 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 who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis. Results Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (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 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.

Introduction: In an effort to improve health outcomes and promote health equity, healthcare systems have increasingly begun to screen patients for unmet social needs and refer them to relevant social services and community-based organizations. This study aimed to identify factors associated with the successful connection (ie, services started) to social needs resources, as well as factors associated with an attempt to connect as a secondary, intermediate outcome. Methods: This retrospective cohort study included patients who had been screened, referred, and subsequently reached for follow-up navigation from March 2019 to December 2020, as part of a social needs intervention at a federally qualified health center (FQHC). Measures included demographic and social needs covariates collected during screening, as well as resource-related covariates that characterized the referred resources, including service domain (area of need addressed), service site (integration relative to the FQHC), and access modality (means of accessing services). Results: Of the 501 patients in the analytic sample, 32.7% had started services with 1 or more of their referred resources within 4 weeks of the initial referral, and 63.3% had at least attempted to contact 1 referred resource, whether or not they were able to start services. Receiving a referral to resources that patients could access via phone call or drop-in visit, as opposed to resources that required additional appointments or applications prior to accessing services, was associated with increased odds (aOR 1.95, 95% CI 1.05, 3.61) of connection success, after adjusting for age, sex, race, ethnicity, education, number of social needs, and resource-related characteristics. This study did not find statistically significant associations between connection attempt and any variable included in adjusted analyses. Conclusion: These findings suggest that referral pathways may influence the success of patients’ connection to social needs resources, highlighting opportunities for more accessible solutions to addressing patients’ unmet social needs.

R efugees in the United States face multiple unique challenges related to acculturation, meeting basic needs, and accessing vital services such as health care [1]. Structural and contextual factors, such as "othering" and discrimination, are potential pathways through which acculturation can erode the health of refugees and their descendants [2]. Although experiences of trauma, displacement, and disruptions in health care are not unique to refugees, the experience of real or threatened danger is a defining characteristic of this population, and traumatic experiences may directly contribute to suboptimal acculturation, health care access, and health outcomes [3].Difficulties in health care access upon arrival in the United States include barriers to navigating complex medical and insurance systems, overcoming language and cultural barriers, institutional mistrust, and the residual impacts of trauma and challenging experiences prior to and during migration [1,4]. These challenges exacerbate health inequities and place families and individuals with refugee status at undue risk for numerous health issues.The barriers to health care faced by newly arrived refugees may be particularly challenging for children, who may fail to receive preventive care, lack proper nutrition, and experience developmental delays, all of which may be due to the often chaotic resettlement process and delayed access to care upon arrival in the United States [5]. Mental health issues are especially prevalent among refugee children, who are exposed to trauma before, during, and after the resettlement process [6,7].The North Carolina Triangle area (comprised of Durham, Chapel Hill, Raleigh, and their surrounding areas) has long been an important center for refugee resettlement in the state and in the southern United States. In recent years, refugees settling in North Carolina have come from diverse locations including Afghanistan, Central African Republic,