An Innovative Nurse Navigator Approach to Screen For and Address Social Needs in a Veterans Health Administration Women’s Health Clinic

Abstract

Background:

Women Veterans are the fastest-growing population in the Veterans Health Administration (VHA), but little is known about how to identify and address their social needs. This program evaluation examined the implementation of a social screening and referral initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), using nurse navigators in a VHA women’s health clinic.

Objectives:

(1) Describe the implementation process and outcome measures, (2) assess the prevalence of women Veterans’ social needs, (3) characterize nurse navigators’ perceptions of ACORN, and (4) document implementation challenges and adaptations.

Research Design:

Program evaluation with qualitative and quantitative data collected between March 2023 and November 2024. Descriptive statistics were used to summarize sociodemographic characteristics and social needs of Veterans screened.

Subjects:

Veterans receiving continuity care at a women’s health clinic in a midwestern VHA hospital.

Results:

Nurse navigators completed ACORN screens with 291 Veterans, with 67% screening positive. The most frequently reported needs were social isolation/loneliness (49%), utilities (17%), transportation (14%), and digital needs (13%). Nurse navigators and the nurse site champion reported that ACORN enhanced their understanding of patients’ social needs and their ability to address these needs. They also reported seamless integration of ACORN into existing workflows.

Conclusions:

Findings show early insights into women Veterans’ unique social needs. An innovative nurse navigator approach to social screening in a VHA women’s health clinic was feasible, had high likelihood of sustainment, and improved nurses’ ability to care for their patients. This indicates strong potential for expanding nurse navigator roles both within and outside VHA.

The Veterans Health Administration (VHA), the nation’s largest integrated health care system and a leader in social and medical care integration, has made significant strides to identify and address social needs.^1–3 Social needs are social, physical, and economic factors that affect people’s health and well-being and contribute to at least 50% of health outcomes.^4,5 Unmet social needs result in delayed and missed care, avoidable acute health care utilization, and higher health care costs.^6,7 In VHA, the nursing workforce is uniquely positioned to facilitate social screening and referrals given nurses’ integral role across the patient care continuum and recurring touch points with patients.⁸ This is especially relevant for women Veterans, who are the fastest growing subset of the Veteran population and who have distinct health care experiences and needs.^9,10 Recommendations from the American College of Obstetricians and Gynecologists, professional nursing societies, and The Joint Commission call for systematic social screening and referrals, particularly in high-risk populations such as pregnant women.^11–14

Despite these recommendations, evidence-based tools to guide nurses and interprofessional teams to identify and address social needs within women’s health settings remain limited, and little is known about women Veterans’ social needs.¹⁵ The relationship between social needs and women Veterans' military experiences and its influence on physical and mental health is complex and requires further exploration into appropriate care models.^16,17 Assessing Circumstances and Offering Resources for Needs (ACORN) is a clinical intervention implemented in partnership with the VHA Office of Health Equity and National Social Work Program that aims to systematically screen for, assess, and address social needs to improve health and well-being among all Veterans.^3,18,19 ACORN consists of a standardized screening tool and the provision of relevant resources and referrals for 9 social need domains: food insecurity, housing instability, utility needs, lack of access to transportation, legal needs, educational assistance/resources, employment needs, social isolation/loneliness, and digital needs (including device and internet access and digital health literacy).¹⁹

In VHA primary care settings, ACORN has generally been implemented by social workers because of their biopsychosocial practice model, familiarity with available resources and referrals, and alignment of ACORN with their existing workflows.²⁰ Most often, social workers use ACORN with individuals referred to them by another care team member for an identified need. This limits the use of ACORN for those who are not identified as having an unmet need. Involving nursing allows for systematic screening at an earlier point of care and presents an opportunity to administer ACORN with those who may not otherwise be seen by social work. Nurses are uniquely positioned to conduct social screening and referrals due to the variety of roles and responsibilities they serve on interdisciplinary teams.⁸ Nurses’ roles can involve care management, direct patient care, and patient education among others, which makes them a critical part of routine care and present in most care interactions.^21,22 By promoting interprofessional partnerships within the largest clinical workforce in the United States, which consists of 100,000 nurses, 20,000 social workers, and thousands of other interdisciplinary team members, including peer specialists, the VHA can systematically identify and address social needs among all Veterans.²³

Although ACORN has expanded to nearly 85 Veterans Affairs Medical Centers (VAMCs), uptake has been low in women’s health settings and few efforts target Women’s Health-Patient Aligned Care Teams (WH-PACT). Among unique Veterans screened in fiscal year 2024, only 3% were from women’s health settings. The Patient Aligned Care Team (PACT) model is similar to patient-centered medical homes and emphasizes a team-based primary care approach (Fig. 1).²⁴ WH-PACTs implement the PACT model in settings specifically tailored to women Veterans and include women’s health nurse navigators to provide routine care management for preventative care and maternity care.^25–27 The nurse navigator role is well-suited for ACORN integration with their ability to administer social screening alongside other routine screenings focused on proactive and preventive care and a unique opportunity to apply their care coordination approaches to follow-up longitudinally recognizing that needs may change.

FIGURE 1.

Women’s Health Patient Aligned Care Team (WH-PACT) model for the Midwestern VAMC program evaluation. The provider, PACT RN care manager, health tech/LPN, and medical support assistant represent the core care team. The Women’s Health RN navigators are extended care team roles specific to the WH-PACT. LPN indicates licensed practical nurse; RN represents registered nurse.

Integrating ACORN into women’s health settings provides an opportunity for nurses to lead social screening and referral interventions, improve care coordination, and advance health equity. Increasing nurse involvement in social screening and referral efforts expands health care systems’ potential ability to systematically screen patients and improve patient care delivery. In fiscal years 2023 and 2024, the Office of Health Equity provided seed funding to support ACORN implementation in a WH-PACT at a Midwestern VAMC. We aimed to: (1) describe process and outcome measures of ACORN implementation (e.g., workflow development, nurse navigator role integration, screening approaches); (2) assess the prevalence of social needs among women Veterans; (3) characterize nurse navigators’ perceptions of ACORN; and (4) document implementation challenges and adaptations made by the clinic to sustain and improve the process.

METHODS

This program evaluation leverages qualitative and quantitative data to describe nurse navigator roles in implementing ACORN into a WH-PACT in a Midwestern VAMC.²⁸ Implementation of ACORN began at this site in March 2023, with data collected through November 30, 2024. Veterans receiving continuity care at the WH-PACT were eligible for screening. Screening was administered as part of maternity care coordination and preventative care management outreach.

Setting and Participants

The PACT model provides patient-driven, team-based primary care focused on wellness and disease prevention. The core team consists of a provider, nurse (RN) case manager, licensed practical nurse, and an administrative clerk.²⁹ The model leverages an extended care team of dieticians, pharmacists, and social workers for referral as needed. WH-PACT includes all the above with mandated additional nurse navigator roles on the core team focused on preventative care (e.g., mammograms, cervical cancer screening, maternity care, and care coordination) and maternity care coordination (monthly meetings with Veterans throughout pregnancy and up to 12 mo postpartum) (Fig. 1).^25–27 This midwestern clinic is the only VAMC that has divided their women’s health coordination workflows into 2 teams: maternity care and preventive care (i.e., pap smears, mammograms, and cervical cancer screening). Within their preventive care approach, they provide targeted outreach to women of reproductive age and those of postmenopausal age. The clinic’s WH-PACT model facilitated a team-based approach, where nurse navigators already had a key role in preventive care management with existing Veteran outreach, making them well-suited to lead ACORN screening.

Implementation Process and Workflow

Although initial implementation plans included administration of ACORN by the nurse navigators and the WH-PACT social worker, staff turnover before ACORN implementation delayed social worker involvement. This turnover presented an opportunity for nurse navigators to fill a larger role in implementation efforts than originally planned, leading the clinic to be one of the first to implement a nurse-driven ACORN screening and referral workflow. Nurse navigators and the nurse site champion, a women’s health program manager, met regularly to develop an implementation workflow based on their WH-PACT model, resources, and staffing capacity. Figure 2 depicts the initial ACORN workflow developed by the WH-PACT site champion and nurse navigators, as well as their refined workflow once they incorporated self-administered electronic screening.

FIGURE 2.

The without eScreening WH-PACT ACORN workflow starts with an administered ACORN screener by the nurse navigator or social worker. Once screened, they review and document the screener in the VHA EHR. If a Veteran screens positive for an urgent need, a consult or warm hand-off will occur. If it is a nonurgent need, the Veteran receives a referral or applicable resources. The referral team or social worker will follow up and continue to address as needed. All Veterans will be rescreened annually. With eScreening (introduced August 2024), the nurse navigator or social worker sends the Veteran the ACORN eScreening before their appointment and reviews responses before the appointment. The same process is followed as above depending on if the screen is positive or negative.

Throughout the first year, the team participated in the national ACORN Community of Practice, a collaborative approach to support implementation and dissemination of ACORN throughout VHA sites and clinical settings.³⁰ The team met monthly with the Office of Health Equity/ACORN staff for workflow feedback, data support, and technical assistance. From March 2023 to July 2024, the ACORN screening tool was administered exclusively by nurse navigators during video telehealth visits using a standardized ACORN electronic health record (EHR) template. In August 2024, an additional pilot was launched where Veterans were able to electronically self-administer the screening tool through eScreening, before their appointment.³¹

If a Veteran screened positive for urgent needs (i.e., acute food, housing, and/or utility needs), the nurse navigator obtained Veteran consent to place an immediate referral or facilitate a warm hand-off to a WH-PACT social worker or mental health provider. Veterans with nonurgent needs were offered relevant resource lists and/or referrals to other clinical services (e.g., social work and nutrition) (Fig. 2). The team also developed and integrated a consult menu into the ACORN EHR template. The consult menu was built for team members to easily select relevant consults and streamline the connection of Veterans screening positive with needed referrals.

Data Collection and Analysis

Data from ACORN and sociodemographic characteristics of Veterans screened (e.g., sex, age, race, and ethnicity) were extracted from the VHA Corporate Data Warehouse, an administrative database. All Veterans who completed ACORN in the WH-PACT during the evaluation period were included. For Veterans screened more than once, we defined their index screen as their first positive screen, or if they never screened positive, then their first screen.^32,33 We summarized sociodemographic and social needs data using descriptive statistics. Each factor was tabulated for frequency counts and percentage breakdown for Veterans screened by the 2 nurse navigators at this WH-PACT.

WH-PACT nurse navigators and the nurse site champion participated in semistructured reflection and feedback sessions to identify their perceptions of ACORN, the implementation process, challenges and successes, and key takeaways.³⁴ Qualitative feedback data from the sessions provided insights on workflow integration, perceived value, and feasibility of implementation and sustainability. For each session, 2 external team members (MD, LR) recorded notes to capture quotes and concepts, followed by team debriefing and memo-ing to compare notes for similarities and summarization of concepts based on emergent content analysis.^35–37 The 2 team members met to discuss data and reach a consensus on the concepts. Findings with key concepts were organized into a table and workflow process maps were developed to represent their year-one process.

RESULTS

Prevalence of Social Needs

Between March 2023 and November 2024, 291 Veterans were screened with ACORN in the WH-PACT (Table 1). Veterans’ mean age was 51 years (SD: 16.2); 72% of Veterans were Non-Hispanic or Latino White, 8% Non-Hispanic or Latino Black or African American, and 7% Hispanic or Latino. Forty-two percent lived in rural areas. Thirteen percent of screenings were self-administered through eScreening. The most frequently reported social needs were social isolation/loneliness (49%), utilities (17%), transportation (14%), and digital needs (13%).³³ Among those screening positive, 67% received a resource or referral, 21% reported already receiving services/assistance, and 10% declined assistance. The most common types of resources and referrals provided to Veterans screening positive were a warm hand-off to or consult for social work (27%), resource lists or guides (25%), and/or a warm hand-off to or consult for mental health (11%).

TABLE 1.

Sociodemographic Characteristics and Social Needs of Veterans Screened With ACORN in the VHA Women’s Health Clinic

Characteristics	Veterans (n=291), n (%)
Sex
Female	289 (99.3)
Male	2 (0.7)
Age, mean (SD)	50.8 (16.2)
Age
18–34	77 (26.5)
35–49	58 (19.9)
50–64	86 (29.6)
≥ 65	70 (24.1)
Race/ethnicity*
Non-Hispanic White	208 (71.5)
Non-Hispanic Black or African American	22 (7.6)
Hispanic or Latino	21 (7.2)
Other†	14 (4.8)
Unknown/missing	26 (8.9)
Relationship status
Divorced/separated/widowed	116 (39.9)
Married/partnered	116 (39.9)
Single, never married	46 (15.8)
Unknown/missing	13 (4.5)
VA Rurality‡
Urban	167 (57.4)
Rural	123 (42.3)
Unknown/missing	1 (0.3)
Enrollment priority§
Service connected	197 (67.7)
Nonservice connected and low-income	49 (16.8)
Nonservice connected and above the VA means test	44 (15.1)
Unknown/missing	1 (0.3)
Screens through eScreening	38 (13.1)
Social needs identified
Any need	194 (66.7)
Social isolation/loneliness	141 (48.5)
Utilities	48 (16.5)
Transportation	41 (14.1)
Digital needs	39 (13.4)
Food insecurity	36 (12.4)
Employment	26 (8.9)
Legal needs	21 (7.2)
Educational needs	20 (6.9)
Housing instability	17 (5.8)
Resource/referral outcomes
Received a resource/referral	129 (66.5)
Already receiving assistance	40 (20.6)
Declined assistance	20 (10.3)

^*Race and ethnicity are based on the racial and ethnic groups recognized in the 1997 Office of Management and Budget guidance and currently used in the VHA. Race and ethnicity have been combined per the VHA Office of Health Equity’s approach to race and ethnicity categorization. This approach means that any Veteran who identifies as Hispanic or Latino appears only in that category and not in a race category, even if a race was selected in addition to Hispanic and Latino ethnicity in the Veteran’s electronic health record.

^†Veterans belonging to other racial groups (shown above as “Other”) include those classified as American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, as well as those with more than one race captured in their medical record.

^‡Rurality refers to the Veteran’s rurality based on the most recent address listed in their medical record. These data are based on the Rural-Urban Commuting Areas (RUCA) System developed by the US Department of Agriculture and the U.S. Department of Health and Human Services. There are 3 categories reported: urban, rural, and highly rural. We combined rural and highly rural for our analyses due to small cell sizes.

^§Enrollment priority determines US Veterans’ eligibility for, and cost-share associated with, VA health services. We collapsed Enrollment Priority Group into 3 categories: (a) Veterans receiving some percentage service-connected disability compensation, Veterans receiving aid and attendance, or having experienced a nonservice-connected catastrophic disability (Groups 1–4; “Service Connected”)); (b) Veterans with no service-connected disability compensation who are low-income (Group 5; “Nonservice Connected and Low-Income”); and (c) those with no service-connected disability compensation who are not low-income (above the VA means test) (Groups 6–8; “Nonservice Connected and Above the VA Means Test”).

ACORN indicates assessing circumstances and offering resources for needs; VHA, Veterans Health Administration.

Reflection and Feedback Sessions

Two reflection and feedback sessions with 3 WH-PACT staff were conducted after the first implementation year. Overall, nurse navigators and the nurse site champion reported that ACORN improved their understanding of patients’ social needs and ability to address these needs, as well as integrated easily into their existing workflow. They also reported that ACORN enriched their understanding of the social, physical, and environmental circumstances of patients receiving care in the WH-PACT and reinforced nurses’ central role in patient advocacy.

In terms of successes, this clinic found that nurse navigators were able to adapt ACORN for a nurse navigator-driven workflow since the role had dedicated time for patient outreach and could seamlessly integrate social needs screening with their existing preventive screenings and care offerings. Nurses’ clinical judgment, communication skills, and existing, long-standing patient relationships allowed for effective navigation of both urgent and nonurgent social needs. The clinic’s EHR-based consult menu was shared as a best practice and innovation through the ACORN Community of Practice and has since been adapted by other VAMCs using ACORN.³⁰ Although the consult menu facilitates easy placement of referrals to other needed services, the team is seeking to improve their ability to create a closed-loop referral mechanism to track completed referrals and receipt of support. In addition, this WH-PACT began piloting eScreening for Veteran self-administration of ACORN in August 2024. The original ACORN pilot utilized electronic self-administered ACORN screening on a VHA-owned tablet in the waiting room.³ However, this is the first clinic to enable Veterans to self-administer ACORN screening on their own electronic device in advance of their appointment, which required significant refinement to the WH-PACT’s existing ACORN workflow and a methodical approach to ensure appropriate follow-up services were provided.

While WH-PACT nurse navigators and site champions felt the pilot was successful, they also identified challenges to ACORN implementation. Initial implementation plans included additional administration of the ACORN screening tool by the WH-PACT social worker but, due to staff turnover, screening was delayed for this role. The WH-PACT nurse navigators and site champion further described delays in building resource guides, challenges with referral capacity where not all services could support the intake volume from the clinic (including WH-PACT social work due to staffing shortages), and the inability to track if Veterans received relevant support from the VHA services for which they were referred. Since the WH-PACT began screening before the release of the ACORN Dashboard,³⁰ the team reported difficulty in obtaining relevant data to inform local QI efforts in which they aimed to pilot, test, and reassess their workflow. They also reported that shifting priorities around clinical programs and staffing influenced screening volume.

Lessons Learned From Implementation

Among these successes and challenges, the women’s health clinic applied innovative approaches and adaptations to succeed in initial implementation and maintain screening and referral efforts. Key lessons learned included:

• Start slow (e.g., identify a subset of the Veteran population to screen and include selection criteria in clinic workflow) and demonstrate effectiveness and success before spreading to additional clinical settings and roles.

• Be mindful of how social screening and referrals may impact other roles and services due to an influx of referrals resulting from positive screens.

• Communication within and across care teams is key.

• Tracking screening data is critical to understanding how needs may change seasonally.

• Connecting Veterans to technology resources (e.g., VHA Health Resource Centers, VHA-loaned internet-connected devices) can improve their access and communication with care teams, especially for Veterans in rural areas who may live further from VAMCs.

Plans for Sustainment

The WH-PACT discussed multiple avenues for expansion as they enter their third implementation year. Since the pilot described in this program evaluation, the WH-PACT has been able to include a WH-PACT Social Worker and have further expanded to include 2 pharmacy technicians who serve a variety of PACT settings. To enhance their consult menu and resource guide, they added a chaplain services consult and aim to develop a quick response (QR) code to make accessing resource guides easier for Veterans. Driven by a strong desire to integrate social screening and referrals into this VAMC’s culture and reach as many Veterans as possible, the ACORN champion disseminated ACORN beyond the WH-PACT nurse navigators to 2 WH-PACT nurses on other teams. To facilitate this expansion and obtain buy-in, the ACORN champion collaborated with social work and nursing leadership.

DISCUSSION

This program evaluation demonstrates the feasibility of a nurse navigator-led social screening and referral intervention within a women’s health clinic. Nurse navigators’ reported receptivity to ACORN, easy integration into existing workflows, and a high likelihood of sustainment as evidenced by their dissemination to additional roles. Findings also support the potential for expansion of nurse-led use of ACORN across other clinical settings. Since social screening and referrals facilitated by nurse navigators in the VHA is novel, their successful implementation of ACORN along with their perception of ACORN’s benefits for women Veterans indicates that nurses in this role are well-positioned to screen for, assess, and address social needs.

Women Veterans in this WH-PACT most frequently endorsed social isolation/loneliness, utilities, transportation, and digital needs. Women Veterans have unique health care needs requiring comprehensive, trauma-informed care that considers their higher rates of service-connected disability, military sexual trauma, and mental health conditions.^9,38,39 The intersection between women Veterans’ military experiences, trauma, and social needs is complex, with several studies demonstrating increased risk for and endorsement of different types of social needs compared with their male counterparts.^16,17 Recognition of how women Veterans’ social needs may be impacted by these factors is imperative to appropriately tailor screening and intervention approaches.

Nursing and Health-Related Social Needs

Nurses have successfully implemented social needs screening and referral across health care settings outside of VHA and are integral to expanding ACORN across PACT team roles.^8,40 This program evaluation shows how nurses can be leveraged in social screening and referral, and support social workers in sharing the workload to increase the number of Veterans reached. Veterans may interact with different aspects of the health care system at different times, and it is critical to recognize that if screening is restricted to one role or discipline, many Veterans may have their needs go unidentified and unaddressed. However, nurses are an integral part of the care continuum and provide health care services for patients in every step of their care journeys. Without the inclusion of nursing, efforts to systematically identify and address social needs among all Veterans will be limited. The success of this program evaluation supports multiple PACT roles— including nurses—involvement with ACORN to spread this clinical intervention and reach more Veterans. ACORN integration across interdisciplinary team roles is key to implementing systematic screening and referrals for social needs and decreasing overall clinical team burden, particularly for social workers.²⁰

This program evaluation is directly relevant to the VHA Nursing Research Agenda, Future of Nursing Report, and American Nurses Association Standards of Practice as it highlights how nurses can optimize practice through improved care coordination, utilization of social screening and referral interventions, and teamwork within the PACT model.^41–43 By integrating social screening and referral into existing workflows, nurses may mitigate burnout, reduce fragmentation of care, and improve their own job satisfaction by developing pathways to address social needs.^40,44 Lessons learned from the pilot—such as starting small, managing referral volumes, and maintaining open communication with the variety of staff roles and disciplines involved in managing the provision of resources and referrals—can guide other VHA and non-VHA women’s health settings interested in adopting nurse-led social screening and referral interventions.

Women’s Health and Social Needs

Limited evidence exists on women Veterans’ social needs; a recent systematic review on women Veterans’ health literature found that only 3% of the 932 articles discussed social determinants or drivers of health, the upstream manifestations of social needs.^10,45 While nurses are integral to women’s health care coordination, there are few care models that integrate social screening and referral with existing nursing workflows. Patient navigation in women’s health has shown success in reducing cancer care disparities and has the potential for similar results in obstetric and gynecologic care.⁴⁶ Maternity care coordination has been found to improve birth weights and pre-term birth rates in some studies but few programs report on social screening and referral as a program component.^47,48 In programs that did include social screening, most only screened for interpersonal violence and not a broader set of social needs such as the 9 ACORN domains.⁴⁹ Since ACORN no longer includes an interpersonal violence question, current evidence may support reincorporating this domain into screening in women’s health settings.⁴⁹

There are a few considerations unique to social screening and referral programs in population-specific clinics, such as women’s health, including the ability to tailor screening and workflows to a specific population and address intersectionality, both with social needs and specific resources. Specialty PACTs often have additional resources and roles that incorporate enhanced care coordination and team communication strategies that are optimal for social screening and referral integration. The model presented in this program evaluation is novel in its embedment of social screening and referral into nurse-led maternity and preventative care coordination. Future research is needed to scale and evaluate the impact of these programs on women’s health outcomes as well as to examine women Veterans’ perspectives on social screening and referrals.

Limitations

Our findings should be interpreted within the context of several limitations. First, this initiative took place in one Midwestern WH-PACT, which may limit generalizability. Second, the input from staff was gathered through feedback and reflection sessions, so our conclusions are limited due to the small sample and informal nature of data collection. The reported acceptability and importance of ACORN may have been subject to social desirability bias.

CONCLUSIONS

As the number of women Veterans grows, with projected growth to 18% of the total US Veteran population by 2040, it is imperative to include the nursing workforce in social screening and referral interventions.^9,50 Health care systems must equip care teams with the training, resources, and time to adapt social screening and referral interventions for women Veterans’ needs and gather feedback about their experience with clinical interventions like ACORN. This is one of the first models to demonstrate that comprehensive social screening and referrals can be successfully embedded into nurse-led maternity and preventative care coordination and adds to the limited existing literature on women Veterans’ health. Our findings highlight the types of social needs experienced by women Veterans and underscore the importance of a flexible nurse-led approach that can address both traditional resource gaps and emerging concerns like digital access and digital health literacy. This program evaluation serves as a model for VHA and non-VHA women’s health settings to integrate social screening and referral interventions into nurses’ workflows as part of the solution for identifying and addressing social needs, thereby advancing patient-centered and equitable care delivery.