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. Author manuscript; available in PMC: 2025 Jun 17.
Published in final edited form as: Annu Rev Public Health. 2024 Oct 30;46(1):151–170. doi: 10.1146/annurev-publhealth-071823-111332

Table 1.

Summary of determinants of social needs screening and referral across multiple levels of the social care implementation framework

Determinantsa
Awareness (screening) Assistance (referral)
Societal influences
Sociopolitical forces Culture, stigma, and discrimination for having social needs (B)
Policies, laws, and regulations (B, F)

  • Social care quality measures

  • Public policies regarding staff credentialing and reimbursement

 Culture, stigma, and discrimination for receiving help for social needs (B)
Policies, laws, and regulations (B, F)

  • Reimbursement waivers (Medicaid 1115)

  • Policies on data sharing, privacy, and confidentiality


Chronic underfunding of social safety net (B)
Physical structures Health care access (B, F) Limited public transportation (B)
Density, reach, and diversity of SSOs available (B, F)
Clinical context
Recipients (patients) Knowledge, attitudes, and beliefs

  • perception of screening as acceptable, appropriate (F)

  • uncertainty over how information is used, documented (B)

  • discomfort with sharing sensitive information (B)

  • fear of being judged/discrimination (B)

  • parents’ fear of being reported (B)


Previous experiences (positive and negative) with health care, screening (B, F)
Quality of relationship with provider (B, F)		 Lack of desire to receive referrals (B)
Previous experiences (positive and negative) with health care, assistance (B, F)
Quality of relationship with provider (B, F)
Recipients (providers and care team members) Knowledge, attitudes, and beliefs

  • understanding of SDOH and impact of social needs on health (F)

  • belief that screening is important and useful and that it helps improve care (F)

  • beliefs about alignment of screening with professional role (B, F)

  • lack of knowledge of available resources to address social needs/perception of resources as inadequate (B)

  • concern about negative patient perceptions, reactions (B)


Skill and experience (B, F)
Discomfort, low self-efficacy for screening/discussing social needs (B)		 Knowledge, attitudes, and beliefs

  • Uncertainty that patients’ needs will be met (B)

  • beliefs about alignment of assistance with professional role (B, F)

Knowledge of resources and personal relationships with SSOs (F)
Characteristics of the screening innovation Relative complexity (B) or simplicity (F) of screening tool and process

  • Accessible literacy level (F)

  • Language (B, F)

Appropriateness of screening tool and modality for patients (B, F)
Quality of evidence for screening (B, F)		 Inclusion of questions on which social risks the patient desires/needs support with (F)
Inner setting Extent of alignment between screening practices and routine clinical workflows (B, F)
Limited time and competing demands during clinic visit (B)
Dedicated staff to support screening (B, F)
Funding, investment in staff, infrastructure (B, F)
Organizational priority, leadership support (B, F)		 Extent of alignment between assistance practices and routine clinical workflows (B, F)
Limited time and competing demands during clinic visit (B)
No or part-time team members dedicated to assistance (B)
Care team members (e.g., social workers, CHWs) with expertise in assistance (F)
Funding, investment in staff, infrastructure (B, F)
Organizational priority, leadership support (B, F)
Bridging factors and referrals
Characteristics of the referral innovation NA Presence of SSRLs and customized resource directories (B, F)
SSRLs have limited capacity or access to universal databases to maintain resource information (B)
Service fees for bidirectional referral and communication (B)
Alignment of SSRL with health care and SSO workflows (B, F)
Integration of SSRLs in the EHR (F)
Relationships NA Bidirectional communication and referral pathways (F)
Effective communication and shared goals (F)
Quality/trusting relationship (F)
Lack of service agreements (B)
Social service context
Inner setting NA Specialized services to support unmet social needs (F)
Strong ties in the community (trusting relationships with the people they serve) (F)
Long waitlists to access resources and strict eligibility requirements (B)
Limited resources (staff, services) to address patients’ needs and keep resource offerings up to date (B)
Limited capacity to engage with and maintain SSRLs (B)

Abbreviations: CHWs, community health workers; EHR, electronic health record; NA, not applicable; SDOH, social determinants of health; SSO, social service organization; SSRL, social service referral locator.

a

Determinants may be a barrier (B) or facilitator (F), depending on their presence or absence and relative positive or negative effect.