Figure 1.

Social determinants of health (SDOH) screening and referrals workflow. The figure above illustrates the 2 types of workflows that were implemented across the health centers. Health centers followed the same SDOH screening procedure that consisted of patients completing the measure in the waiting room. Clinic staff reviewed the results and generated a referral for the provider to sign when SDOH needs were identified. Once the referral was signed, health centers either sent the referral (1) directly to onsite managers and resource staff or (2) to be processed by an off-site central team of patient navigators before it was sent to on-site managers and resource staff. Once the referral reached the on-site managers and resource staff, patients were contacted for meetings and assistance was provided.