Challenge/Facilitator	Qualitative Evaluation Findings
Challenge: Integration of screen into workflow	A key lesson that emerged from early implementation was the importance of integrating all aspects of the screening process into existing workflows to avoid the perception that it was something “special” or “additional” (e.g., registration clerks at one site initially gave the screening tool to patients as a separate document when they checked in for their appointments, which resulted in a high rate of noncompletion because handing the tool to patients was an extra step for clerks, and some patients perceived the tool as optional). The registration clerks then integrated the screening tool into the standard packet of forms and screens given to all patients. This simple tweak “normalized” the screening tool for both clerks and patients, and program staff reported a much higher screening rate as a result.
Challenge: Burden on staff	One of the biggest issues all three sites faced was how to screen and refer patients without placing undue burden on existing staff. Staffing challenges existed throughout the workflow, from the initial point of screening, to reviewing the screen with patients, to making and receiving referrals. Clinics addressed some staffing challenges (e.g., one site switched the role of screening administrator from nurses to trained, clinic-based volunteers after nurses indicated that the task was too burdensome given their existing responsibilities).
Challenge: Patient-related factors	Low literacy, limited English proficiency, concerns about immigration status, and screening fatigue posed challenges to screening. Even with substantial refining of the language on the screening tools, respondents at all three sites identified patients’ language and literacy levels as significant and continuing barriers to completion of the screening tool.
Challenge: Tracking capability	Respondents recognized the value of tracking screening and referrals to assess progress and gaps but acknowledged that consistent tracking was time consuming and thus challenging. One site tracked data ad hoc using an electronic database, but respondents identified this as a strain on time. Toward the end of the pilot period, all sites began researching the use of technology to streamline data tracking and facilitate other aspects of the SDOH screening process, including making referrals to the social work department through the electronic health record system. In addition, sites had access to NowPow,7 a social services referral software system, to help identify resources for patients who screened positive for various issues. NowPow can also track whether patients receive the services to which they are referred (closed-loop referrals); however, that functionality had not yet been rolled out to the sites at the time of the pilot program.
Facilitator: History of community-based partnerships and colocated services	All clinics participating in this pilot had a history of referring patients to various internal and external services, albeit unsystematically, before this initiative. Perhaps as a result, respondents did not note significant gaps or barriers in identifying appropriate services to which to refer patients to address their social needs. Each site also benefited from the existence of a number of social services and services colocated within their facilities, including legal services, home health care, and enrollment in the federal Supplemental Nutrition Assistance Program (SNAP). Leadership at one site described challenges in finding referral resources outside the local hospital area, as many of their patients do not live near the hospital and therefore are outside the catchment area for many of the hospital’s local community-based organization partners.