Best Practice	Related Findings
Ensure the screening tool is appropriate in terms of literacy, culture, and language	Concerns about literacy and patients’ understanding of the screening tool were paramount at all sites. Modifications to the Center for Medicare and Medicaid Innovation–based screening tool included adding items, eliminating items, and rewording items. Despite operating within the same health care system in the same city, each clinic ended up with its own unique tool adapted to its specific workflows and population served.
Integrate screening into regular clinic workflows	The site that included the screening tool in the packet of materials all patients receive on registration illustrated the value of making social needs screening a part of regular clinic registration procedures and not something extra or optional for staff and patients alike. We recommend including the screening tool or integrating it into the regular set of forms that patients receive at clinic visit registration.
Make screening universal	Providing screening tools only to certain subsets of the clinic population, such as patients with scheduled appointments or specific patient panels within the clinic, was burdensome for registration staff and subsequently led to lower completion rates. All three sites initially decided to screen only patients with scheduled appointments, but one of the adult clinics eventually transitioned to screening every patient at every visit, which enhanced screening rates and reduced the burden on registration clerks and patients.
Establish a solid referral base	Universal screening only provides value when systems can address patients’ identified needs through internal resources or referrals to community resources. The sites in our pilot benefited from established relationships with community partners and colocated services.
Maximize the use of technology	All three sites used an electronic referral system, but none were yet using such systems to screen patients. Respondents were clear that technology both reduced staff burden and increased screening rates. Integrating the screening tool into the existing electronic health record using referral software such as NowPow or a combination of the two could enhance the ease and universality of the screening and referral process.
Implement a data-tracking system	Sites should be able to track patients throughout the screening process, from initial screen to referral and ultimately receipt of services. Such a system facilitates program monitoring and identification of gaps in the workflow and provides evidence of the value of the program. NYC New York City Health + Hospitals has integrated the screening tool into its electronic health record, allowing more sophisticated data tracking, and is currently pursuing the use of NowPow to track referrals.
Staff the program appropriately	Optimal staffing includes a dedicated program coordinator to implement and monitor the program. Respondents were somewhat divided on whether using volunteer staff was feasible or sustainable, with frontline staff in particular strongly favoring paid staff over volunteers. If volunteers are the most feasible option, it is critical that they be committed to the program’s success, thoroughly trained on clinic operations and workflows, and well known to staff and providers. Staff coverage during all clinic hours is also important to ensure that all patients are screened.