Table 3. Characteristics of Included Studies, Screening and Referral to Identify Unmet Health-Related Social Needs in Health Care Settings.
| Author, Year; Location (Reference) | Setting; Target Population | Screening Tool and Targeted Unmet Health-Related Social Need | Referral Approach; Referral Site | Study Design, Sample Sizea | Outcome Assessed | Summary of Results |
|---|---|---|---|---|---|---|
| Experience of care outcomes | ||||||
| Smith S, 2016; San Diego, CA (53) | Setting: 3 student-run free clinics. Population: Adults (aged >18 y) | USDA US Household Food Security Survey 30-day version, targeted food insecurity | Approach: Indirect referralb with on-site assistance.c Site: Local food pantries, monthly on-site food distributions, and on-site same-day SNAP enrollment | Cross-sectional study, 1-group design (n = 430) | Experience of care (referral uptaked) | 15% (66 of 430) of total patients used a food pantry. 15% (64 of 430) enrolled in SNAP. 48% (208 of 430) of screened patients had diabetes, of whom 97% (201 of 208) received on-site monthly food boxes |
| Fox CK, 2016; Minnesota (37) | Setting: 1 pediatric weight management clinic. Population: Households with children | Hunger Vital Sign, targeted food insecurity | Approach: Direct referral.e Site: Food bank (Second Harvest Heartland) offered on-site assistance with SNAP application | Prospective pilot study, 1-group design (n = 116) | Experience of care (referral uptaked) | 8% (3 of 40) of eligible patients completed SNAP enrollment process. |
| Palakshappa D, 2017; Pennsylvania (47) | Setting: 6 pediatric clinics. Population: Households with children | Hunger Vital Sign in EHR, targeted food insecurity | Approach: Direct referral.e Site: Nonprofit organization (Benefits Data Trust) assisted with applications to government benefits | Prospective mixed-methods study, 1-group design (n = 4,371) | Experience of care (referral uptaked) | 26% (32 of 122) of patients with food insecurity consented to a direct referral. 3% (1 of 32) of patients enrolled in SNAP. |
| Stenmark SH, 2018; Colorado (54) | Setting: 2 pediatric clinics. Population: Households with children | Hunger Vital Sign, targeted food insecurity | Approach: Indirect referralb evolved into direct referral.e Site: Nonprofit organization (Hunger Free Colorado) offered assistance with applications to federal and community resources | Descriptive, prospective study, 1-group design, number of screened patients not provided; 1,586 patients were referred | Experience of care (referral uptaked) | Connection rate between patients and referral site increased from 5% to 75% after the program moved from indirect to direct referral. 6% (100 of 1,586) of patients enrolled in SNAP. |
| Marpadga S, 2019; San Francisco, CA (45) | Setting: 1 diabetes clinic. Population: Patients with diabetes | Hunger Vital Sign, targeted food insecurity | Approach: Indirect referralb with on-site assistance.c Site: Multiple, including programs that offered free groceries, on-site prepared meals, home-delivered meals, and medically tailored meals (Project Open Hand) | Qualitative study; semistructured interviews, 1-group design (n = 240) | Experience of care (referral uptaked) | 13% (31 of 240) of screened patients were interviewed. 32% (10 of 31) of participants connected with food resources: 3% (1 patient) with a program providing free groceries and 29% (9 patients) with a program providing medically tailored meals. |
| Beck AF, 2012; Cincinnati, OH (29) | Setting: 1 pediatric primary care clinic. Population: Households with children | EHR-based screening, targeted poor housing conditions | Approach: Warm handoff.f Site: On-site medical–legal partnership offered help with legal housing problems | Descriptive, retrospective study, 1-group design, number of screened patients not provided, 16 caregivers referred | Experience of care (referral uptaked) | 71% (10 of 14) of referred housing units with outcome data resulted in housing condition repairs. 58% (11 of 19) of building complexes with the same owner received substantial systemic repairs. |
| Silverstein M, 2004; Seattle, WA (27) | Setting: 4 health clinics. Population: Low-income households with children | Program-developed tool, targeted education | Approach: Intervention: Direct referral.e Control: Indirect referral.b Site: US Department of Health and Human Services program (Head Start) | Randomized controlled trial, intervention (n = 123) vs control (n = 123) | Experience of care (referral uptaked) | Intervention group had more children who connected with the education resource (41%, 50 of 123 vs 18%, 22 of 123; adjusted difference, 17%; 95% CI, 8%–27%) and more children who actively attended the program (25%, 31 of 123 vs 11%, 14 of 123; adjusted difference, 12%; 95% CI, 3%–21%) than the control group. |
| Dicker RA, 2009; San Francisco, CA (33) | Setting: 1 level I trauma center. Population: Patients aged between 12–30 | Screening tool (not specified) targeted risk of reinjury | Approach: Warm handofff. Site: Case management services, including help with court advocacy, driver’s license, educational resources, vocational training, mental health and drug treatment, and more | Program evaluation study, 1-group design, number of screened patients not provided, 44 enrolled | Experience of care (referral uptaked) | 23% of patients with a positive screen for unmet health-related social needs (45 of 195) received full case management services including help with court advocacy, education, vocational training, mental health/drug treatment, employment needs, housing needs, and receiving a driver’s license. |
| Coker AL, 2012; Unknown location (32) | Setting: 6 primary care clinics. Population: Women (aged >18 years) | Program-developed tool (56) targeted intimate partner violence | Approach: Intervention: Indirect referral,b warm handoff,f and on-site assistance.c Control: Indirect referral.b Site: Multiple, including coalition services, safety planning, and on-site counseling and support (intervention group only) | Quasi-experimental, longitudinal cohort study, intervention (n = 138) vs control (n = 93) | Experience of care (referral uptaked) | A similar number of women reported using the referral resource in the intervention and control group (21.4% vs 17.4%; P = .43). More intervention women connected with the on-site advocate (32.8% vs 4.4%; P < .001) and had lower IPV scores and fewer depressive symptoms (P = .07; P = .01) than the control. |
| Klein MD, 2013; Cincinnati, OH (43) | Setting: 3 pediatric clinics. Population: Households with children | EHR-based screening (57) targeted income, child food insecurity, poor housing conditions, domestic violence, parental depression, and anhedonia | Approach: Warm handoff.f Site: On-site medical–legal partnership offered help with legal problems | Descriptive cohort study, number of enrolled participants not provided, 1-group design; 1,614 patients referred | Experience of care (referral uptaked) | 1,617 legal cases were pursued by 1,614 referred families. 90% (1,742 of 1,945) of legal outcomes were positive, including improvements in housing conditions, public benefits, education, or provision of legal advice. 10% (n = 203) related to either inability to reconnect with the family or issue resolution. |
| Uwemedimo OT, 2018; Queens, NY (55) | Setting: 1 hospital-based pediatric practice. Population: Households with children (<18 y) | FAMNEEDS targeted parent counseling and education needs, food insecurity, housing/utility insecurity, interpersonal safety, transportation, unemployment | Approach: Warm handofff before indirect referral.b Site: Unspecified partner CBOs | Pre-post intervention study, 1-group design (n = 148) | Experience of care (referral uptaked) | 31% (46 of 148) of households reported using the program-provided resources at 12-month follow-up. More limited English proficiency caregivers used resources (38.4% vs 18.4%, P = .03) than English-proficient caregivers, and more noncitizen caregivers used referrals (37.4% vs 23.1%, P = .04) than US citizens. |
| Garg A, 2015; Boston, MA (23) | Setting: 8 community health centers. Population: Households with infants (<6 mo) | Program-developed tool targeted parent education needs, childcare needs, food insecurity, housing insecurity, unemployment | Approach: Intervention: Indirect referralb with on-site assistance.c Control: Indirect referral.b Site: Unspecified CBOs | Randomized controlled trial, intervention (n = 168) vs control (n = 168) | Experience of care (referral uptaked) | Intervention mothers were more likely to enroll in a new community resource (39% vs 24%; aOR = 2.1; 95% CI, 1.2–3.7), had greater odds of being employed or enrolled in a job training program (aOR = 44.4; 95% CI, 9.8–201.4), receiving childcare support (aOR = 6.3; 95% CI, 1.5–26.0), fuel assistance (aOR = 11.9; 95% CI, 1.7–82.9), and lower odds of being in a homeless shelter (aOR = 0.2; 95% CI, 0.1–0.9) than mothers in control group. |
| Fiori KP, 2020; Bronx, NY (35) | Setting: 1 pediatric clinic. Population: Households with children | EHR-based Health Leads–adapted tool targeted poor access to health care, childcare and eldercare needs, food insecurity, housing insecurity, interpersonal safety, legal needs, transportation | Approach: Warm handoff.f Site: Unspecified CBOs | Pragmatic prospective cohort study, 1-group design (n = 4,948) | Experience of care (referral uptaked) | 43% (123 of 287) of patients referred to a community health worker had “successful” referrals. These patients either accessed, obtained, or used the recommended community-based service or support. |
| Pettignano R, 2011; Atlanta, GA (49) | Setting: 1 pediatric clinic. Population: Households with children with sickle cell disease | Screening tool (not specified) targeted legal needs associated with child needs (eg, childcare, child abuse), education, health insurance, interpersonal safety, unemployment, food insecurity, housing insecurity, and income insecurity | Approach: Warm handofff to HeLP program with on-site assistance.c Site: On-site medical–legal partnership offered help with legal problems | Descriptive, retrospective cohort study, number of enrolled participants not provided, 1-group design, 69 patients referred | Experience of care (referral uptaked) | 106 legal cases were pursued by 69 referred households. 93% (n = 99) of the cases were closed. 21% (21 of 99) of the closed cases resulted in measurable gain of benefits including obtaining food stamps, Social Security insurance, family stability, employment, and/or housing and education benefits. |
| Garg A, 2012; Baltimore, MD (39) | Setting: 1 pediatric clinic. Population: Households with children | Health Leads targeted education needs, food insecurity, health insurance, housing insecurity, income insecurity, interpersonal safety, transportation needs, unemployment | Approach: Indirect referral.b Site: Unspecified CBOs | Prospective cohort study, 1-group design (n = 1,059) | Experience of care (referral uptaked) | 50% (530 of 1,059) of families enrolled in at least 1 community-based resource within 6 months of accessing the on-site Health Leads desk. |
| Power-Hays A, 2020; Boston, MA (50) | Setting: 1 pediatric hematology clinic. Population: Patients with sickle cell disease | The WE CARE app targeted childcare needs, educational needs, food insecurity, housing insecurity, income insecurity, transportation needs, unemployment | Approach: Indirect referralb or warm handoff.f Site: Unspecified local CBOs | Qualitative quality improvement project, 1-group design (n = 132) | Experience of care (referral uptaked) | 45% (42 of 92) of patients who were referred and available for follow-up reported reaching out to the CBO. |
| Hassan A, 2015; Boston, MA (40) | Setting: 1 adolescent/young adult clinic. Population: Patients aged 15–25 | Program-developed tool targeted access to health care, education needs, food insecurity, housing insecurity, income insecurity, fitness and safety equipment needs, unemployment | Approach: Indirect referral.b Site: Unspecified CBOs | Prospective interventional study, 1-group design (n = 401) | Experience of care (referral uptaked, patient-reported outcomes) | 40% (104 of 259) of patients with a positive screen contacted the referral site of which 50% (52 of 104) had their problem resolved. 60% (155 of 259) did not contact the referral site but 45% (70 of 155) reported having resolved their problem. |
| Krasnoff M, 2002; Unknown location (44) | Setting: 1 level I trauma center. Population: Women aged 18–65 | Partner Violence Screen (58) targeted IPV | Approach: Warm handoff.f Site: On-site case manager and other unspecified community-based resources | Observational case study, 1-group design (n = 528) | Experience of care (referral uptaked, patient-reported outcomes) | 84% (475 of 562) of women with a positive screen consented to meeting with an on-site advocate, of whom 54% (258 of 475) then agreed to meet with a case manager. At follow-up, 24% (127 of the 528) of women reported they no longer believed they were at risk for violence from their abuser. |
| Haas JS, 2015; Boston, MA (25) | Setting(s): 13 primary care clinics. Population: Adults that smoke | Web-based referral system HelpSteps targeted multiple social needs | Approach: Intervention: Direct referrale before indirect referral.b Control: No referral. Site: External specialist (direct referral), unspecified CBOs (indirect referral), and provision of free NRT patches | Randomized clinical trial, intervention (n = 399) vs control (n = 308) | Experience of care (referral uptaked, patient-reported outcomes) | 68.7% (274 of 399) of intervention participants connected with the external tobacco treatment specialist, while 20.1% reported using the HelpSteps referral. Intervention participants who connected with the specialist (21.2% vs 10.4%; P = .009) or used the HelpSteps referral (43.6% vs 15.3%; P < .001) were more likely to quit than those who did not. |
| Hsu C, 2019; San Pablo, CA (41) | Setting: 1 primary care practice. Population: Adults | Health Leads targeted childcare needs, food insecurity, health literacy, housing insecurity, income insecurity, transportation | Approach: Warm handoff.f Site: Unspecified community-based resources | Qualitative study; semistructured interviews, 1-group design (n = 102) | Experience of care (referral uptake, patient-reported outcomes) | Patients reported concrete changes in their lives including healthier diets, decreased stress or worry, and increased feeling of stability; some reported as resolved immediate food, transportation, or health care needs, and others reported physical or mental/emotional benefits. |
| Fleegler EW, 2007; Boston, MA (36) | Setting: 2 pediatric clinics. Population: Households with children aged 0–6 | Program-developed tool targeted poor access to health care, food insecurity, housing insecurity, income insecurity, and intimate partner violence | Approach: Indirect referralb Site: Unspecified local agencies | Cross-sectional descriptive study, 1-group design (n = 450) | Experience of care (referral uptaked, patient satisfaction) | 63% (73 of 115) of referrals received by 79 households led to contact with the referral agency. 82% (60 of the 73) of households considered their referral sites helpful. |
| Garg A, 2010; Baltimore, MD (38) | Setting: 1 medical home. Population: Households with children | WE CARE-based tool targeted child needs (eg, after-school programs, childcare, child school failure), education needs, food insecurity, health insurance, housing insecurity, public benefits needs, income insecurity, IPV, unemployment, safety equipment, and other (eg, smoking, drug or alcohol abuse) | Approach: Warm handoff.f Site: Unspecified CBOs | Longitudinal cohort pilot study, 1-group design (n = 59) | Experience of care (referral uptaked, patient satisfaction) | 32% (19 of 59) of parents that used the on-site Help Desk reported enrolling in at least 1 community program. 21% (4 of the 19) enrolled in ≥2 community programs. More than 90% of parents who enrolled in a community resource were very or somewhat satisfied. |
| Gottlieb LM, 2016; San Francisco and Oakland, CA (24) | Setting: 2 safety-net hospitals. Population: Households with children | 14-item questionnaire targeted needs related to childcare, education, food insecurity, health insurance, housing insecurity, income insecurity, interpersonal safety, legal aid, transportation, unemployment | Approach: Intervention: Warm handoff.f Control: Indirect referral.b Site: Unspecified community, hospital, and government-based resources | Randomized clinical trial, intervention (n = 872) vs control (n = 937) | Experience of care (patient-reported outcomes) | At 4-months postenrollment, intervention participants reported fewer unmet social needs (mean change of −0.39 vs 0.22; P < .001) and greater improvement in their child’s health than control participants (mean change of −0.36 vs 0.12; P < .001). |
| Dubowitz H, 2009; Baltimore, MD (21) | Setting: 1 pediatric clinic. Population: Households with children aged 0–5 | Parent Screening Questionnaire (59) targeted child maltreatment risk factors including parental depression, parental substance abuse, harsh punishment, major parental stress | Approach: Intervention: Indirect referralb and warm handoff,f if needed. Control: No referral. Site: Multiple, including local community resources and on-site social workers | Randomized controlled trial, intervention (n = 308) vs control (n = 250) | Experience of care (patient-reported outcomes) | Postintervention, the intervention group had fewer families that filed child protective services reports (13.3% vs 19.2%; P = .03), and fewer instances of possible medical neglect including nonadherence (4.6% vs 8.4%; P = .05) and delayed immunizations (3.3% vs 9.6%; P = .002) than the control group. Control group had more parent-reported harsh punishment (P = .04). |
| Dubowitz H, 2012; Maryland (34) | Setting: 18 pediatric practices. Population: Mothers with children | Parent Screening Questionnaire (59) targeted child maltreatment risk factors including parental depression, parental substance abuse, harsh punishment, major parental stress | Approach: Intervention: Indirect referralb and warm handofff if needed. Control: No referral. Site: Multiple, including local community resources and on-site social workers | Case-control study; intervention (n = 595) vs control (n = 524) | Experience of care (patient-reported outcomes) | Intervention mothers reported less psychological aggression initially and 12 months later (initial effect size P = .006; 12-month effect size P = .047) and fewer minor physical assaults (initial effect size P = .02; 12-month effect size P = .04) than control. |
| Population health outcomes | ||||||
| Beck AF, 2014, Cincinnati, OH (30) | Setting: 1 pediatric clinic. Population: Households with infant(s) aged <12 months | Hunger Vital Sign targeted food insecurity | Approach: Recipients: Indirect referralb and on-site assistance.c Nonrecipients: No referral. Site: Unspecified CBOs and on-site provision of formula cans | Prospective, difference-in-difference study, recipients (n = 1,042) vs nonrecipients (n = 4,029) | Experience of care (referral uptaked), Health | Experience of care: All recipients were more likely to have been referred to social work (29.2% vs 17.6%; P < .001), or the medical–legal partnership (14.8% vs 5.7%; P < .001) than nonrecipients. Health: By 14 months, recipients versus nonrecipients were more likely to have completed a lead test and developmental screen (both P < .001), and a full set of well-infant visits (42% vs 28.7%; P < .001). |
| Sege R, 2015; Boston, MA (26) | Setting: 1 hospital-based pediatric clinic. Population: Households with newborn aged <10 weeks | Screening tool (not specified) targeted food insecurity, housing insecurity, income insecurity | Approach: Intervention: Warm handoff.f Control: No referral. Site: On-site medical–legal partnership | Randomized controlled trial, intervention (n = 167) vs control (n = 163) | Experience of care (referral uptaked), Health | Experience of care: Intervention versus control showed accelerated access to resources (baseline, 2.8% vs 1.6%; 6 months, 3.2% vs 2.7%; 12 months, 3.7% vs 3.2%; P = .03). Health: Intervention versus control group had more infants that completed their 6-month immunization schedule by age 7 and 8 months (77% vs 63%; P < .005 and 88% vs 78%; P < .01, respectively), more likely to have ≥5 routine preventive care visits by age 1 year (78% vs 67%; P < .01), and less likely to have visited the emergency department by age 6 months (37% vs 50%; P = .021). |
| Patel MR, 2018; Michigan (48) | Setting: 1 endocrinology clinic. Population: Patients with diabetes | Program-developed tool targeted financial burdens | Approach: Indirect referral.b Site: Unspecified local and national resources for financial burden and disease management | 1-group pre–post pilot study (n = 104) | Experience of care (referral uptaked, patient satisfaction), Health | Experience of care: More participants were using low-cost resources at 2-month follow-up compared with baseline, such as online diabetes education (40% vs 29%; P = .05) and assistance programs related to blood glucose supplies (40% vs 16%; P = .03). Participants found the resource tool highly acceptable across 15 indicators (eg, 93% “learned a lot,” 98% “topics relevant”). Health: Fewer patients reported skipping doses of medicines due to cost concerns (4% vs 11%; P = .03) compared with baseline. |
| Smith R, 2013; San Francisco, CA (52) | Setting: 1 hospital. Population: Victims of violent trauma aged 10–30 years | Screening tool (not specified) targeted high risk for reinjury and others, including need for court advocacy, driver’s license, education, employment, family counseling, housing, mental health, vocational/professional training, substance abuse help | Approach: Warm handoff.f Site: Unspecified risk-reduction resources | Retrospective cohort study, 1-group design (n = 141) | Experience of care (referral uptaked), Health | Experience of care: For 6 years of the program, 254 clients received on-site case management services; a total of 617 needs were identified. 70% (430 of 617) of identified needs were met. Health: The violent injury recidivism rate dropped from an initial 16% to 4.5% by the end of the program. |
| Berkowitz SA, 2017; Boston, MA (31) | Setting: 3 primary care practices. Population: Adults with chronic disease | Health Leads targeted access to medications, elder care needs, food insecurity, housing insecurity, income insecurity, transportation needs, unemployment | Approach: Participants: Warm handoff.f Nonparticipants: No referral. Site: Unspecified CBOs and public benefits | Pragmatic difference-in-difference evaluation study, participants (n = 1,021) vs nonparticipants (n = 301) | Experience of care (referral uptaked), Health | Experience of care: 58% (1,021 of 1,774) of patients with a positive screen enrolled in the program and connected with the on-site advocate. 29.7% of reported needs were closed as “successful,” 27.9% as “equipped,” 34.9% as “unsuccessful,” and 7.1% were handled with a rapid resource referral. Health: Participants versus nonparticipants demonstrated greater improvement in blood pressure (SBP differential change −1.2; 95% CI, −2.1 to −0.4; DBP differential change −1.0; 95% CI, −1.5 to −0.5), and LDL-C (differential change −3.7; 95% CI, −6.7 to −0.6), but no change in HbA1c (differential change −0.04%; 95% CI, −0.17% to 0.10%). |
| Morales ME, 2016; Chelsea, MA (46) | Setting: 1 obstetric clinic. Population: Women | Program-developed tool targeted food insecurity | Approach: Recipients: Indirect referralb and on-site assistance.c Nonrecipients: No referral. Site: Food for Families program, which included referral to local food pantries and on-site support with SNAP or WIC enrollment | Retrospective cohort study, 2-group design, recipients (n = 145) vs nonrecipients (n = 145) | Experience of care (referral uptaked), Health | Experience of care: 67% (97 of 145) of women referred to the program enrolled. Health: Recipients demonstrated better blood pressure trends during pregnancy (SBP 0.2015 mm Hg/wk lower; P = .006 and DBP 0.1049 mm Hg/wk lower; P = .02). No blood pressure trend among nonrecipients, and no differences in blood glucose trends between the 2 groups (P = .40). |
| Ferrer RL, 2019; San Antonio, TX (22) | Setting: 1 primary care clinic. Population: Patients with type 2 diabetes | Hunger Vital Sign targeted food insecurity | Approach: Intervention: Warm handoff.f Control: Indirect referral.b Site: Regional food bank | Randomized controlled trial, intervention (n = 19) vs control (n = 24) | Experience of care (patient-reported outcomes), Health | Experience of care: Intervention group received an average of 7.8 food allotments and were visited at home by a community health worker an average of 2.6 times. Health: Intervention versus control demonstrated a greater drop in HbA1c levels (mean difference of −3.09 vs −1.66; P = .01), improved STC-Diet scale (mean differences of 2.47 vs 0.06; P = .001), but no significant BMI difference (mean differences of –0.17 vs 0.84; P = .43). |
| Cost-related outcomes | ||||||
| Aiyer JN, 2019; North Pasadena, TX (28) | Setting: 1 federally qualified health center and 2 school-based clinics. Population: Households with children | Hunger Vital Sign targeted food insecurity | Approach: Indirect referral.b Site: Food prescription to local food pantry | 1-group design, pre–post mixed methods evaluation study, n = 242 | Experience of care (referral uptaked, patient-reported outcomes), Cost-related (program costs) | Experience of care: 71.1% (172 of 242) of referred patients redeemed their prescription at the food pantry. 94.1% (162 of 172) participants reported a decrease in the prevalence of their food insecurity. Cost-related: Program costs was $12.20 per participant per prescription redemption. |
| Schickedanz A, 2019; Southern CA (51) | Setting: 1 health care system. Population: Predicted high-utilizer patients | Health Leads targeted child-related needs, educational needs, food insecurity, housing insecurity, income insecurity, transportation needs, unemployment | Approach: Intervention: Indirect referral.b Control: No referral. Site: Multiple community-based resources including food banks, housing programs, and other agencies | Prospective difference-in-difference study, intervention (n = 7,107) vs control (n = 27,118) | Experience of care (referral uptaked), Cost-related (utilization) | Experience of care: 53% (1,984 of 3,721) of screened participants reported social needs, but only 10% of those connected with resources. Cost-related: Intervention versus control showed 2.2% decline in utilization visits (P = .058) over 1-year postintervention, including emergency department visits, inpatient hospitalizations, and ambulatory visits. Greater declines in total utilization for all low-socioeconomic status subgroups in intervention versus control (P < .001). |
| Juillard C, 2015; San Francisco, CA (42) | Refer to Smith R, 2013 (52) | Refer to Smith R, 2013 (52) | Refer to Smith R, 2013 (52) | Cost-effectiveness analysis of Smith R, 2013 (52) | Cost-related (cost effectiveness and cost savings) | Cost-related: Realized substantial health benefits (24 QALYs) and savings ($4,100) if implemented for 100 people. |
Abbreviations: BMI, body mass index; CBO, community-based organization; DBP, diastolic blood pressure in mm Hg; EHR, electronic health record; HbA1c, hemoglobin A1c; FAMNEEDS, Family Needs Screening Program; HeLP Program, Health Law Partnership; IPV, intimate partner violence; KIND, Keeping Infants Nourished and Developing; LDL-C, low-density lipoprotein cholesterol in mg/dL; NRT, nicotine replacement therapy; QALYs, quality-adjusted life years; SBP, systolic blood pressure in mmHg; SNAP, Supplemental Nutrition Assistance Program; USDA US HFSS, US Department of Agriculture US Household Food Security Survey; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
a
Reported as the total number of participants who underwent screening. If the study did not report number of screenings, the number of referrals was reported as the sample size.
b
A referral approach in which health care providers simply hand over information about relevant referral sites to the patient (eg, a list of local food banks and their contact information).
c
Additional on-site services may include assistance with applying to community-based resources or connection to other resources through a helpdesk, and/or on-site provision of supplies.
d
Refers to participants who connected to necessary resources expressed as a percentage or ratio of all participants who had a positive screen or those who consented to a referral.
e
A referral approach that requires the patient’s consent to forward their contact information to the corresponding internal or external resource. The referral site then directly contacts the patient.
f
A referral approach in which patients are introduced to an on-site intermediary person in the health care organization (eg, community health worker, case manager) who works to connect them to referral sites.