Box 1.

DESCRIPTION OF IMPLEMENTATION AND MAINTENANCE PHASE ACTIVITIES

Phase	Activity	Description	Associated Personnel	Exemplar Activities
Implementation	Planning & workflow design	Meetings with leadership, clinical informatics, and behavioral health integration to design patient-centered clinical workflows and embed screening and response protocols within existing quality improvement and population health management initiatives.	• Nursing (RN) • Medical provider • Healthcare social workers (MSW) • Health information technician • Leadership	• Identifying priority patient populations for engagement. • Designing delivery and clinical workflows via regular quality improvement cycles. • Identifying and preparing clinical champions and clinician implementation teams. • Assessing for readiness by identifying implementation barriers and facilitators.
	Workforce development*	Training and workforce development activities ranging from EHR documentation for quality assurance to best practices for engaging patients around social needs. This includes skill building in motivational interviewing, reflective listening, shared decision-making, and empathie communication techniques to discuss potentially sensitive non-medical dimensions of health.	• Nursing (CNA, LPN, and RN) • Medical provider • Healthcare social worker • Health information technician • Leadership	• Attending clinical conferences and webinars related to social needs screening and response • Continued medical education related to evidence based strategies for engaging with patients • Continued professional development for leveraging social needs assessment data for population health management, grant writing, and advocacy.
	EHR integration	Creation and customization of an EHR flowsheet template. This also includes quality assurance activities and troubleshooting. EHR integration implementation activities are designed to ensure that members of patients’ care teams can access data on social needs to inform care planning and generate customizable reports.	• Nursing (RN) • Medical provider • Health information technician • Leadership	• Designing EHR data entry fields through iterative testing and quality assurance. • Importing pre-existing SDOH template from EHR vendor. • Iterative auditing and providing feedback through testing cycles.
Implementation	CBO directory development and updates*	The result of these activities is the compilation of an up-to-date and curated directory of community resources and social services that patients may qualify for. This includes coordination and communication with local agencies and CBOs to confirm relevant details for referrals including capacity, eligibility requirements, and hours of operation.	• Nursing (CNA) • Healthcare social workers (MSW and LCSW) • CHW	• Accessing information on local health and human services. • Compiling contact information for CBOs. • Establishing formal or informal partnerships with CBOs to establish referral pathways through community meetings, county health department initiatives, and internal meetings. • Updating to directory of relevant resources and CBOs as a result of regular or semi-regular community scans.
Maintenance	Social needs screening	Effort and resource inputs associated with clinical activities to administer the social needs screening tool during or before a visit. This also includes effort or resources associated with social need and referral documentation on paper and/or in the patient EHR.	• Nursing (CNA, LPN, and RN) • Medical provider • Healthcare social workers (MSW and LCSW)	• Patient self-administers social needs screening as an element of patient in-take • Social needs screening administration by a member of the health care team via interview to a patient population of interest (e.g., post-partum women or patients that receive a behavioral health referral). • Data entry of social needs assessment responses into the patients’ EHR. This includes patients with no identified social needs and referrals offered.
	CBO referrals	Activities and clinical effort to refer patients to CBOs or social services based on needs identified through screening. This ranges from providing information on relevant resources to assisting with making initial contact. These activities are only completed for patients with identified needs.	• Nursing (CNA, LPN, and RN) • Healthcare social workers (MSW and LCSW)	• Behavioral health case manager refers patient to social service agency or CBO based on eligibility and unmet social need. Information is provided to the patient via a handout with information on contacting, applying, hours, and/or eligibility requirements. • If unmet social need is associated with affording medication, RN makes a specialized referral for a medication assistance program. • If referral resource is available within the health center, a warm hand-off is made.
Maintenance	Case management	Activities that apply for a subset of complex patients that require ongoing case management to resolve CBO referral(s). This includes regular follow-up on unmet social needs at subsequent visits or additional telephonic case management.	• Nursing (CNA, LPN, and RN) • Medical providers • Healthcare social workers (MSW and LCSW) • CHW	• Follow-up on referrals as part of Medicare chronic care management visits to promote self-management goals. • CHW telephonic outreach for case management activities.
	Data reporting, analysis & quality improvement	Activities involving personnel effort or technologies associated with generating reports using social needs assessment and referral data for strategic planning, workflow design, and population health management or quality improvement initiatives.	• Nursing (RN) • Medical provider • Healthcare social worker • Health information technician • Leadership	• Monthly project team meetings to plan or execute quality improvement activities (e.g., modifying practice patterns). • Generating reports using social needs assessment data to present at provider huddles, for leadership, or for Uniform Data System reporting requirements. • Presenting data on transportation-related social needs for a monthly coalition meeting with CBOs and community stakeholders

Note:

^*Activities consist of one-time capacity building and ongoing clinical activities spanning both implementation and maintenance phases

CBO = Community based organization

EHR = Electronic health record

RN = Registered nurse

LPN = Licensed practical nurse

MSW = Master of social work

LCSW = Licensed clinical social worker

CHW = Community health worker

CNA = Certified nursing assistant