TABLE 2:

Plan-Do-Study-Act cycles

Distribution of screener: Sept-Nov, 2017
Plan	Screeners were initially distributed by the hematologist or social worker depending on who saw the patient first. The perception of this strategy was that it was disruptive to clinic flow and did not allow patients enough time to complete the survey; therefore, we wanted to shift this task to the clinical assistants during rooming of the patient.
Do	A meeting was held with clinic staff to explain the importance of screening for social determinants of health, as well as the need for universal screening. A clinic flow diagram was created and available on the back of each paper screener to remind staff of the new flow with space to provide feedback on the process (Supplemental Figure 4A)
Study	Number of surveys distributed was the main outcome measure with no change or increased distribution being considered a successful transition. Feedback from clinicians and clinical assistants was elicited at meetings and via free text areas on the clinical flow diagram without any reported dissatisfaction or notable delays. Our additional balancing measure was the proportion of positive screens with a resultant resource sheet.
Act	After this PDSA cycle, clinical assistants were primarily responsible for survey distribution.
Timing of Screening: January, 2018
Plan	Because subspecialty care does not occur at pre-determined intervals the way that primary well child care does, the screening intervals did not have a natural pattern. We initially set out to screen families every three months because in our patient population socioeconomic needs, such as employment and housing can change rapidly. Many families, however, verbalized that screening every 3 months was too frequent.
Do	Screening was spaced to every 6 months.
Study	Proportions of surveys completed out of those that were due continued to be tracked. Clinical assistants felt positively about this change at staff meetings, and the social worker did not note any increase in unmet emergent needs.
Identification of patients due for screening, September, 2018
Plan	Initially, the administrative coordinator tracked screening of patients with SCD and designated that they were due every 3–6 months in the electronic schedule.
Do	To further reduce the administrative burden and to streamline the clinic flow, it was decided to distribute screening at all non-sick or non-urgent appointments. Clinic staff were updated during staff meetings and the clinic flow diagram was updated.
Study	The number of screeners documented in the EMR per patient with SCD per clinic visit was recorded, so the denominator of this process measure was adjusted.
Act	All patients with SCD are offered a screener at every non-sick or non-urgent care visit.
Documentation of screener results, September-November, 2018
Plan	Clinical assistants across the hospital had been trained to document a housing screener. Therefore, the clinic agreed that this should continue to be their role.
Do	When the clinic resumed the full SDoH screen, we designated it as the clinical assistants’ task to document the screener in the EMR.
Study	Process measures and balancing measures continued to be tracked. There was a sharp decline in distribution of resource referrals when providers were no longer recording the screener into the EMR themselves. This was reviewed and providers were reminded to review the flowsheets. Clinical assistants were also asked to page the social workers if there was a positive result. Clinical assistants reported some occasional lack of clarity in the process, but overall agreed with the change.
Act	Clinical assistants record screener results into the EMR and page SW for a positive screen. Physicians review all screening results in EMR.
Socioeconomic needs screened for: September-October, 2017
Plan	The initial screener was based on the WECARE screener that asked six questions. The primary care clinic at our hospital updated their screener to ask about ability to pay for medications and transportation to clinic. When considering adopting this change as well, we returned to our main criteria to guide which socioeconomic need to include which was that there was an available resource to address that need; this exists for these two questions. Patients with Massachusetts Medicaid and certain chronic medical conditions, including sickle cell disease, qualify for transportation to clinic visits and should have the majority of their medications covered. Prior to introducing WECARE, our clinic had been proactively setting up this transportation assistance for many families, particularly because many families in Boston do not have cars and the exposure to the cold winter while waiting for the bus can be detrimental to our patients.
Do	We adopted the updated screener and notified staff to discard the older version (which was printed on yellow rather than blue paper).
Study	This change was made relatively early in our study and changes in enrollment in transportation assistance were not tracked; however, there was no associated disruption in clinic flow with the addition of these questions reported on our clinical diagram or in clinical meetings.
Act	The 8-question screener was adopted.