Table 4.

Illustrative quotes on system-level barriers and facilitators that influence awareness of and providing assistance for social needs screening in primary care.

	Barriers to awareness about social needs	Facilitators to awareness about social needs
Awareness of social needs	Lack of public health messaging to normalize social needs elicitation Participant 6 (Executive Director of Population Health): “My first part is what advocacy are we doing? Social needs issues (are) coming to the providers and the health system, but on the public health (side), what are we doing? Have we created that awareness that people understand and anticipate that this is good for them? That they should be comfortable talking to their doctors about their food insecurity issues, food safety issues and whatnot? They’ve never seen the doctor in that light. State and federal governments will have to work harder to help them understand that when you go to your doctor, please fill in this questionnaire.”	State funds to support social needs screening and training Participant 2 (Director of Population Health Management): “We had meetings where everyone (in the practice was) involved: the providers, MAs, registrars. And there was a presentation on what the HEART program is and how the social needs screening workflow would go.”
	EHR barriers: time-consuming documentation, non-value-added “box checking,” lack of data sharing, difficulties in data integration Participant 12 (Physician): “And, to be honest with you, I'm gonna speak for all the doctors and nurses and PAs and all that out there, but we're doing 500 different things. And we keep adding stuff. Somebody's gonna die for every (EHR documentation) field that we create.” Participant 19 (Practice Manager): “How do you integrate that information into the flow in that who within the clinical team then says, “Hey, Mr. Smith might end up in several of our cohorts. He might be diabetic; he might be a frequent flyer to the ED. He might be getting a high likelihood of clinical event score.” How do you put all of those siloed pieces of information together to provide Mr. Smith with the best care?”	EHR facilitators: access previously completed screening results, advanced data analytics to offer services to targeted groups Participant 19 (Practice Manager): “We have noticed that we have a lot of our HEART recipients coming from one zip code. Over the last couple of days, surveys have been sent out to all of our patients in that zip code, asking them questions about social needs, like transportation, ability to pay for their prescriptions. Do they have an advocate for their health needs? Do they have enough to eat? Are they able to pay for their household commodities like gas and electric oil, water, etc. Prior to just probably the last month or so, it had been just by word of mouth. Now we are proactively trying to create a database of those patients who are in need.”
Assistance to address social needs	Insufficient capacity of community-based organizations to address some social needs Participant 11: “Care management can't, uh, can't really support loneliness, right? Like we can try to connect you with social resources, but especially with the pandemic, like not all seniors with immunocompromising conditions are gonna wanna go to a senior center or the library or whatever else. Um, and there's a lot of, uh, that is a very hard social need to address and probably the one that I most frequently feel as a provider on the front line that I, I can't do a whole lot about. Um, and so it can be hard to screen for something that you feel like you can't impact.”	Using state funds to address patients’ social needs or build practice-level programs (e.g., on-site referrals) Participant 20 (Care Coordinator): “We've used (Aunt Bertha/FindHelp.org). From the MDPCP side, they give us a list of some resources. Meals on Wheels is one of the biggest resources I use. I just Google a lot. I don't really have special ones that I use.”
	Resource lists are difficult to navigate and access Participant 9 (Clinic Supervisor): “Those lists seem to be very cumbersome. There'll be 15 places listed on there and some of ‘em may not be where (patients) can get to them.”	Increasing awareness about community resources Participant 10 (Community Health Worker): “I'm their first and only community health worker so far, but we've grown from like three care managers to six now in two years. So I think the providers are more aware of that these are the people that can help me with these patients.”