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Annual Review of Public Health

Volume 46, 2025

Integrating Social Needs into Health Care: An Implementation Science Perspective

  • Maura Kepper1, Callie Walsh-Bailey2, Constance Owens-Jasey3, Rose Gunn3 and Rachel Gold3,4
  • 1Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA; email: [email protected] 2Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA 3OCHIN, Inc., Portland, Oregon, USA 4Kaiser Permanente Center for Health Research, Portland, Oregon, USA
  • Vol. 46:151-170 (Volume publication date April 2025)
  • First published as a Review in Advance on October 30, 2024
  • Copyright © 2025 by the author(s).
    This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See credit lines of images or other third-party material in this article for license information.

Abstract

Unmet social needs (e.g., housing instability, food insecurity, transportation barriers) impact a patient's ability to participate in health-seeking behaviors (e.g., physical activity, routine preventive care) and to achieve optimal health. A rapidly growing number of health care systems are incorporating social needs screening and assistance into clinical workflows, yet many implementation and sustainability challenges exist and require collaboration with social service organizations. This review highlights implementation approaches used within this rapidly changing US landscape and uses implementation science frameworks to systematically identify multilevel barriers to and facilitators of implementing and sustaining social needs care. Policies and economic investments are necessary as they determine critical barriers and facilitators within the clinical and social service contexts. Implementation may be further strengthened by cross-sector engagement, evidence-based implementation strategies, and capacity building within clinical and social service organizations. Successful, sustained implementation of social needs care may improve the quality of health care, population health, and health equity.

Keyword(s): health care, health equity, implementation science, social needs, sustainability
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2025-04-04
2025-06-15
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Literature Cited

  1. 1.
    Aarons GA, Hurlburt M, Horwitz SM. 2011.. Advancing a conceptual model of evidence-based practice implementation in public service sectors. . Adm. Policy Ment. Health 38::4–23
     [Crossref] [Google Scholar]
  2. 2.
    ACT CENTER, Wash. Kaiser Perm. 2024.. Designing, implementing, and evaluating a new role to address social health needs in primary care. . Community Resource Specialist. https://www.act-center.org/our-work/focus-areas/social-health/community-resource-specialist
    [Google Scholar]
  3. 3.
    Alderwick H, Gottlieb LM. 2019.. Meanings and misunderstandings: a social determinants of health lexicon for health care systems. . Milbank Q. 97::407–19
     [Crossref] [Google Scholar]
  4. 4.
    Alderwick H, Hood-Ronick CM, Gottlieb LM. 2019.. Medicaid investments to address social needs in Oregon and California. . Health Aff. 38::774–81
     [Crossref] [Google Scholar]
  5. 5.
    Allen P, Pilar M, Walsh-Bailey C, Hooley C, Mazzucca S, et al. 2020.. Quantitative measures of health policy implementation determinants and outcomes: a systematic review. . Implement. Sci. 15::47
     [Crossref] [Google Scholar]
  6. 6.
    Aylward AF, Engelberg Anderson J, Morris A, Bush M, Schmitthenner B, et al. 2021.. Using malnutrition and food insecurity screening to identify broader health-related social needs amongst older adults receiving emergency department care in the Southeastern United States: a cross-sectional study. . Health Soc. Care Community 29::e420–30
     [Crossref] [Google Scholar]
  7. 7.
    Barnidge E, LaBarge G, Krupsky K, Arthur J. 2017.. Screening for food insecurity in pediatric clinical settings: opportunities and barriers. . J. Community Health 42::51–57
     [Crossref] [Google Scholar]
  8. 8.
    Barzargan M, Cobb S, Assari S. 2021.. Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. . Ann. Fam. Med. 19::4–15
     [Crossref] [Google Scholar]
  9. 9.
    Baumann AA, Cabassa LJ. 2020.. Reframing implementation science to address inequities in healthcare delivery. . BMC Health Serv. Res. 20::190
     [Crossref] [Google Scholar]
  10. 10.
    Bradywood A, Leming-Lee TS, Watters R, Blackmore C. 2021.. Implementing screening for social determinants of health using the Core 5 screening tool. . BMJ Open Q. 10::e001362
     [Crossref] [Google Scholar]
  11. 11.
    Bridges KM, LeMaster JW, Parente DJ, Pacheco CM, Schultz C, et al. 2023.. Assessing social needs and engaging community health workers in underserved Kansas counties: insights from primary care providers and clinic managers. . J. Prim. Care Community Health 14::21501319231214513
     [Crossref] [Google Scholar]
  12. 12.
    Brownson RC, Kumanyika SK, Kreuter MW, Haire-Joshu D. 2021.. Implementation science should give higher priority to health equity. . Implement. Sci. 16::28
     [Crossref] [Google Scholar]
  13. 13.
    Buitron de la Vega P, Losi S, Sprague Martinez L, Bovell-Ammon A, Garg A, et al. 2019.. Implementing an EHR-based screening and referral system to address social determinants of health in primary care. . Med. Care 57::S133–39
     [Crossref] [Google Scholar]
  14. 14.
    Byhoff E, De Marchis EH, Hessler D, Fichtenberg C, Adler N, et al. 2019.. Part II: a qualitative study of social risk screening acceptability in patients and caregivers. . Am. J. Prev. Med. 57::S38–46
     [Crossref] [Google Scholar]
  15. 15.
    Careyva BA, Hamadani R, Friel T, Coyne CA. 2018.. A social needs assessment tool for an urban Latino population. . J. Community Health 43::137–45
     [Crossref] [Google Scholar]
  16. 16.
    Cartier Y, Fichtenberg C, Gottlieb L. 2019.. Community resource referral platforms: a guide for health care organizations. Rep. , Soc. Interv. Res. Eval. Netw. (SIREN), San Francisco:
     [Google Scholar]
  17. 17.
    Casanova NL, LeClair AM, Xiao V, Mullikin KR, Lemon SC, et al. 2022.. Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology. . Cancer 128:(Suppl. 13):2649–58
     [Crossref] [Google Scholar]
  18. 18.
    Chriqui JF, Asada Y, Smith NR, Kroll-Desrosiers A, Lemon SC. 2023.. Advancing the science of policy implementation: a call to action for the implementation science field. . Transl. Behav. Med. 13::820–25
     [Crossref] [Google Scholar]
  19. 19.
    Colvin JD, Bettenhausen JL, Anderson-Carpenter KD, Collie-Akers V, Chung PJ. 2016.. Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents. . Acad. Pediatr. 16::161–67
     [Crossref] [Google Scholar]
  20. 20.
    Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. 2009.. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. . Implement. Sci. 4::50
     [Crossref] [Google Scholar]
  21. 21.
    Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J, et al. 2022.. The updated Consolidated Framework for Implementation Research based on user feedback. . Implement. Sci. 17::75
     [Crossref] [Google Scholar]
  22. 22.
    De Marchis E, Knox M, Hessler D, Willard-Grace R, Olayiwola JN, et al. 2019.. Physician burnout and higher clinic capacity to address patients’ social needs. . J. Am. Board Fam. Med. 32::69–78
     [Crossref] [Google Scholar]
  23. 23.
    De Marchis EH, Alderwick H, Gottlieb LM. 2020.. Do patients want help addressing social risks?. J. Am. Board Family Med. 33::170–75
     [Crossref] [Google Scholar]
  24. 24.
    De Marchis EH, Hessler D, Fichtenberg C, Adler N, Byhoff E, et al. 2019.. Part I: A quantitative study of social risk screening acceptability in patients and caregivers. . Am. J. Prev. Med. 57::S25–37
     [Crossref] [Google Scholar]
  25. 25.
    DeFosset AR, Barragan NC, Green G, Morrison JL, Kuo T. 2023.. Building bi-directional referral and communication pathways across the community-clinic divide: experiences from a systems-informed innovation project in Los Angeles. . Healthcare 11::100671
     [Crossref] [Google Scholar]
  26. 26.
    DeWitt C. 2020.. Partnering with research, CRS program addresses social needs in primary care. . Health Findings Blog, Jan. 2. https://www.kpwashingtonresearch.org/news-and-events/blog/2019/december-2019/shaped-research-crs-program-addresses-social-needs-primary-care
    [Google Scholar]
  27. 27.
    Drake C, Batchelder H, Lian T, Cannady M, Weinberger M, et al. 2021.. Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework. . BMC Health Serv. Res. 21::975
     [Crossref] [Google Scholar]
  28. 28.
    Drewry MB, Yanguela J, Khanna A, O'Brien S, Phillips E, et al. 2023.. A systematic review of electronic community resource referral systems. . Am. J. Prev. Med. 65::1142–52
     [Crossref] [Google Scholar]
  29. 29.
    Findhelp. 2022.. Building healthier communities. . Findhelp. https://organizations.findhelp.com/network/
    [Google Scholar]
  30. 30.
    Fiori KP, Rehm CD, Sanderson D, Braganza S, Parsons A, et al. 2020.. Integrating social needs screening and community health workers in primary care: the Community Linkage to Care Program. . Clin. Pediatr. 59::547–56
     [Crossref] [Google Scholar]
  31. 31.
    García Coll C, Lamberty G, Jenkins R, McAdoo HP, Crnic K, et al. 1996.. An integrative model for the study of developmental competencies in minority children. . Child Dev. 67::1891–914
     [Crossref] [Google Scholar]
  32. 32.
    Glasgow RE, Vogt TM, Boles SM. 1999.. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. . Am. J. Public Health 89::1322–27
     [Crossref] [Google Scholar]
  33. 33.
    Gold R, Bunce A, Cowburn S, Dambrun K, Dearing M, et al. 2018.. Adoption of social determinants of health EHR tools by community health centers. . Ann. Fam. Med. 16::399–407
     [Crossref] [Google Scholar]
  34. 34.
    Gold R, Cottrell E, Bunce A, Middendorf M, Hollombe C, et al. 2017.. Developing electronic health record (EHR) strategies related to health center patients' social determinants of health. . J. Am. Board Fam. Med. 30::428–47
     [Crossref] [Google Scholar]
  35. 35.
    Gold R, Gottlieb L. 2019.. National data on social risk screening underscore the need for implementation research. . JAMA Netw. Open 2::e1911513
     [Crossref] [Google Scholar]
  36. 36.
    Gold R, Kaufmann J, Cottrell EK, Bunce A, Sheppler CR, et al. 2023.. Implementation support for a social risk screening and referral process in community health centers. . NEJM Catal. Innov. Care Deliv. 4:. https://doi.org/10.1056/CAT.23.0034
    [Google Scholar]
  37. 37.
    Gottlieb L, Cottrell EK, Park B, Clark KD, Gold R, Fichtenberg C. 2018.. Advancing social prescribing with implementation science. . J. Am. Board Fam. Med. 31::315–21
     [Crossref] [Google Scholar]
  38. 38.
    Gregory AG, Howard D. 2009.. The nonprofit starvation cycle. . Stanford Soc. Innov. Rev. 7::49–53
     [Google Scholar]
  39. 39.
    Gruß I, Bunce A, Davis J, Dambrun K, Cottrell E, Gold R. 2021.. Initiating and implementing social determinants of health data collection in community health centers. . Popul. Health Manag. 24::52–58
     [Crossref] [Google Scholar]
  40. 40.
    Gunn R, Pisciotta M, Volk M, Bowen M, Gold R, Mossman N. 2023.. Implementation of social isolation screening and an integrated community resource referral platform. . J. Am. Board Fam. Med. 36::803–16
     [Crossref] [Google Scholar]
  41. 41.
    Hamity C, Jackson A, Peralta L, Bellows J. 2018.. Perceptions and experience of patients, staff, and clinicians with social needs assessment. . Perm. J. 22::18–105
     [Crossref] [Google Scholar]
  42. 42.
    Henrikson NB, Blasi PR, Dorsey CN, Mettert KD, Nguyen MB, et al. 2019.. Psychometric and pragmatic properties of social risk screening tools: a systematic review. . Am. J. Prev. Med. 57::S13–24
     [Crossref] [Google Scholar]
  43. 43.
    Herrera C-N, Brochier A, Pellicer M, Garg A, Drainoni M-L. 2019.. Implementing social determinants of health screening at community health centers: clinician and staff perspectives. . J. Prim. Care Commun. Health 10::2150132719887260
     [Crossref] [Google Scholar]
  44. 43a.
    Jones CP. 2014.. Systems of power, axes of inequity: parallels, intersections, braiding the strands. . Med. Care 52:(10 Suppl. 3):S7175. Erratum . Med. Care 52:(12):1068
     [Google Scholar]
  45. 44.
    Kaiser Perm. 2019.. Your current life situation. . Systematic Review of Social Risk Screening Tools. https://sdh-tools-review.kpwashingtonresearch.org/screening-tools/your-current-life-situation
    [Google Scholar]
  46. 45.
    Kaiser Perm. Cent. Health Res., OCHIN Inc. 2021.. Guide to implementing social risk screening and referral-making. Rep. , Soc. Interv. Res. Eval. Netw. (SIREN), San Francisco:. https://sirenetwork.ucsf.edu/guide-implementing-social-risk-screening-and-referral-making
    [Google Scholar]
  47. 46.
    Kangovi S, Mitra N, Grande D, Long JA, Asch DA. 2020.. Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. . Health Aff. 39::207–13
     [Crossref] [Google Scholar]
  48. 47.
    Karran EL, Cashin AG, Barker T, Boyd MA, Chiarotto A, et al. 2023.. The ‘what’ and ‘how’ of screening for social needs in healthcare settings: a scoping review. . PeerJ 11::e15263
     [Crossref] [Google Scholar]
  49. 48.
    Kepper MM, Walsh-Bailey C, Prusaczyk B, Zhao M, Herrick C, Foraker R. 2022.. The adoption of social determinants of health documentation in clinical settings. . Health Serv. Res. 58::67–77
     [Crossref] [Google Scholar]
  50. 49.
    Kirchner JE, Smith JL, Powell BJ, Waltz TJ, Proctor EK. 2020.. Getting a clinical innovation into practice: an introduction to implementation strategies. . Psychiatry Res. 283::112467
     [Crossref] [Google Scholar]
  51. 50.
    Korn AR, Walsh-Bailey C, Correa-Mendez M, DelNero P, Pilar M, et al. 2023.. Social determinants of health and US cancer screening interventions: a systematic review. . CA Cancer J. Clin. 73::461–79
     [Crossref] [Google Scholar]
  52. 51.
    Kostelanetz S, Pettapiece-Phillips M, Weems J, Spalding T, Roumie C, et al. 2022.. Health care professionals' perspectives on universal screening of social determinants of health: a mixed-methods study. . Popul. Health Manag. 25::367–74
     [Crossref] [Google Scholar]
  53. 52.
    Kreuter MW, Thompson T, McQueen A, Garg R. 2021.. Addressing social needs in health care settings: evidence, challenges, and opportunities for public health. . Annu. Rev. Public Health 42::329–44
     [Crossref] [Google Scholar]
  54. 53.
    Krieger N. 2020.. Measures of racism, sexism, heterosexism, and gender binarism for health equity research: from structural injustice to embodied harm—an ecosocial analysis. . Annu. Rev. Public Health 41::37–62
     [Crossref] [Google Scholar]
  55. 54.
    LaForge K, Gold R, Cottrell E, Bunce AE, Proser M, et al. 2018.. How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview. . J. Ambul. Care Manag. 41::2–14
     [Crossref] [Google Scholar]
  56. 55.
    Lewis C, Horstman C, Blumenthal D, Abrams MK. 2023.. Value-based care: what it is, and why it's needed. Explain., Commonw. Fund, New York:. https://www.commonwealthfund.org/publications/explainer/2023/feb/value-based-care-what-it-is-why-its-needed
    [Google Scholar]
  57. 56.
    Lewis CC, Klasnja P, Lyon AR, Powell BJ, Lengnick-Hall R, et al. 2022.. The mechanics of implementation strategies and measures: advancing the study of implementation mechanisms. . Implement. Sci. Commun. 3::114
     [Crossref] [Google Scholar]
  58. 57.
    Massar RE, Berry CA, Paul MM. 2022.. Social needs screening and referral in pediatric primary care clinics: a multiple case study. . BMC Health Serv. Res. 22::1369
     [Crossref] [Google Scholar]
  59. 58.
    Morone J. 2017.. An integrative review of social determinants of health assessment and screening tools used in pediatrics. . J. Pediatr. Nurs. 37::22–28
     [Crossref] [Google Scholar]
  60. 59.
    Natl. Acad. Sci. Eng., Inst. Med. 2019.. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC:: Natl. Acad. Press
     [Google Scholar]
  61. 60.
    Nilsen P, Bernhardsson S. 2019.. Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. . BMC Health Serv. Res. 19::189
     [Crossref] [Google Scholar]
  62. 61.
    Norris CM, Lewis CC. 2020.. The impact of the community resource specialist: integrating a lay health worker to address social needs in Kaiser Permanente Washington clinics. . SONNET Newsl. 4:(3). https://www.act-center.org/application/files/5616/3406/5927/SONNET_Newsletter_Vol4_Iss3_Sept_28_2020.pdf
    [Google Scholar]
  63. 62.
    Olayiwola JN, Willard-Grace R, Dubé K, Hessler D, Shunk R, et al. 2018.. Higher perceived clinic capacity to address patients’ social needs associated with lower burnout in primary care providers. . J. Health Care Poor Underserved 29::415–29
     [Crossref] [Google Scholar]
  64. 63.
    Page-Reeves J, Kaufman W, Bleecker M, Norris J, McCalmont K, et al. 2016.. Addressing social determinants of health in a clinic setting: the WellRx pilot in Albuquerque, New Mexico. . J. Am. Board Fam. Med. 29::414–18
     [Crossref] [Google Scholar]
  65. 64.
    Pantell MS, De Marchis E, Bueno A, Gottlieb LM. 2019.. Practice capacity to address patients’ social needs and physician satisfaction and perceived quality of care. . Ann. Fam. Med. 17::42–45
     [Crossref] [Google Scholar]
  66. 65.
    Pescheny JV, Pappas Y, Randhawa G. 2018.. Facilitators and barriers of implementing and delivering social prescribing services: a systematic review. . BMC Health Serv. Res. 18::86
     [Crossref] [Google Scholar]
  67. 66.
    Pfeiffer EJ, De Paula CL, Flores WO, Lavallee AJ. 2022.. Barriers to patients’ acceptance of social care interventions in clinic settings. . Am. J. Prev. Med. 63::S116–21
     [Crossref] [Google Scholar]
  68. 67.
    Potharaju KA, Fields JD, Cemballi AG, Pantell MS, Desai R, et al. 2022.. Assessing alignment of patient and clinician perspectives on community health resources for chronic disease management. Healthcare 10::2006
     [Google Scholar]
  69. 68.
    Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, et al. 2015.. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. . Implement. Sci. 10::21
     [Crossref] [Google Scholar]
  70. 69.
    Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, et al. 2011.. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. . Adm. Policy Ment. Health 38::65–76
     [Crossref] [Google Scholar]
  71. 70.
    Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, et al. 2008.. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. . Adm. Policy Ment. Health 36::24–34
     [Crossref] [Google Scholar]
  72. 71.
    Proctor EK, Powell BJ, McMillen JC. 2013.. Implementation strategies: recommendations for specifying and reporting. . Implement. Sci. 8::139
     [Crossref] [Google Scholar]
  73. 72.
    Quiñones-Rivera A, Wing HE, Barr-Walker J, Yee M, Harrison JM, Gottlieb LM. 2021.. Provider impacts of socioeconomic risk screening and referral programs: a scoping review. . J. Am. Board Fam. Med. 34::820–31
     [Crossref] [Google Scholar]
  74. 73.
    Rohweder C, Wangen M, Black M, Dolinger H, Wolf M, et al. 2019.. Understanding quality improvement collaboratives through an implementation science lens. . Prev. Med. 129::105859
     [Crossref] [Google Scholar]
  75. 74.
    Rosenthal EL, Brownstein JN, Rush CH, Hirsch GR, Willaert AM, et al. 2010.. Community health workers: part of the solution. . Health Aff. 29::1338–42
     [Crossref] [Google Scholar]
  76. 75.
    Schickedanz A, Hamity C, Rogers A, Sharp AL, Jackson A. 2019.. Clinician experiences and attitudes regarding screening for social determinants of health in a large integrated health system. . Med. Care 57::S197–201
     [Crossref] [Google Scholar]
  77. 76.
    Schoenthaler A, Knafl GJ, Fiscella K, Ogedegbe G. 2017.. Addressing the social needs of hypertensive patients: the role of patient-provider communication as a predictor of medication adherence. . Circulation 10::e003659
     [Google Scholar]
  78. 77.
    Schulman M, Thomas-Henkel C. 2019.. Opportunities for complex care programs to address the social determinants of health. Brief, Care Health Care Strateg., Hamilton, NJ:. https://www.chcs.org/media/TCC-SDOH-022119.pdf
    [Google Scholar]
  79. 78.
    Selvaraj K, Ruiz MJ, Aschkenasy J, Chang JD, Heard A, et al. 2019.. Screening for toxic stress risk factors at well-child visits: the addressing social key questions for health study. . J. Pediatr. 205::244–49.e4
     [Crossref] [Google Scholar]
  80. 79.
    Shah M, Heisler M, Davis M. 2014.. Community health workers and the patient protection and Affordable Care Act: an opportunity for a research, advocacy, and policy agenda. . J. Health Care Poor Underserved 25::17–24
     [Crossref] [Google Scholar]
  81. 80.
    Smith JD, Li DH, Rafferty MR. 2020.. The Implementation Research Logic model: a method for planning, executing, reporting, and synthesizing implementation projects. . Implement. Sci. 15::84
     [Crossref] [Google Scholar]
  82. 81.
    Snell-Rood C, Jaramillo ET, Hamilton AB, Raskin SE, Nicosia FM, Willging C. 2021.. Advancing health equity through a theoretically critical implementation science. . Transl. Behav. Med. 11::1617–25
     [Crossref] [Google Scholar]
  83. 82.
    Sokol R, Austin A, Chandler C, Byrum E, Bousquette J, et al. 2019.. Screening children for social determinants of health: a systematic review. . Pediatrics 144::e20191622
     [Crossref] [Google Scholar]
  84. 83.
    Solomon LS, Kanter MH. 2018.. Health care steps up to social determinants of health: current context. . Perm. J. 22::18–139
     [Crossref] [Google Scholar]
  85. 84.
    Spain AK, Monahan EK, Alvarez K, Finno-Velasquez M. 2021.. Latinx family perspectives on social needs screening and referral during well-child visits. MCN Am. . J. Matern. Child Nurs. 46::143–49
     [Crossref] [Google Scholar]
  86. 85.
    Steeves-Reece AL, Totten AM, Broadwell KD, Richardson DM, Nicolaidis C, Davis MM. 2022.. Social needs resource connections: a systematic review of barriers, facilitators, and evaluation. . Am. J. Prev. Med. 62::e303–15
     [Crossref] [Google Scholar]
  87. 86.
    Stein Berman R, Patel MR, Belamarich PF, Gross RS. 2018.. Screening for poverty and poverty-related social determinants of health. . Pediatr. Rev. 39::235–46
     [Crossref] [Google Scholar]
  88. 87.
    Stenmark SH, Steiner JF, Marpadga S, Debor M, Underhill K, Seligman H. 2018.. Lessons learned from implementation of the food insecurity screening and referral program at Kaiser Permanente Colorado. . Perm. J. 22::18-093
     [Crossref] [Google Scholar]
  89. 88.
    Sundar KR. 2018.. Universal screening for social needs in a primary care clinic: a quality improvement approach using the Your Current Life Situation survey. . Perm. J 22::18-089
     [Google Scholar]
  90. 89.
    Theis RP, Blackburn K, Lipori G, Harle CA, Alvarado MM, et al. 2021.. Implementation context for addressing social needs in a learning health system: a qualitative study. . J. Clin. Transl. Sci. 5::e201
     [Crossref] [Google Scholar]
  91. 90.
    Tong ST, Liaw WR, Kashiri PL, Pecsok J, Rozman J, et al. 2018.. Clinician experiences with screening for social needs in primary care. . J. Am. Board Fam. Med. 31::351–63
     [Crossref] [Google Scholar]
  92. 91.
    Tuzzio L, Wellman RD, De Marchis EH, Gottlieb LM, Walsh-Bailey C, et al. 2022.. Social risk factors and desire for assistance among patients receiving subsidized health care insurance in a US-based integrated delivery system. . Ann. Fam. Med. 20::137–44
     [Crossref] [Google Scholar]
  93. 92.
    Wallace AS, Luther BL, Sisler SM, Wong B, Guo J-W. 2021.. Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges. . Implement. Sci. Commun. 2::114
     [Crossref] [Google Scholar]
  94. 93.
    Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, et al. 2015.. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. . Implement. Sci. 10::109
     [Crossref] [Google Scholar]
  95. 94.
    Woodward EN, Matthieu MM, Uchendu US, Rogal S, Kirchner JE, et al. 2019.. The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment. . Implement. Sci. 14::26
     [Crossref] [Google Scholar]
  96. 95.
    Woodward EN, Singh RS, Ndebele-Ngwenya P, Melgar Castillo A, Dickson KS, Kirchner JE. 2021.. A more practical guide to incorporating health equity domains in implementation determinant frameworks. . Implement. Sci. Commun. 2::61
     [Crossref] [Google Scholar]
  97. 96.
    Yan AF, Chen Z, Wang Y, Campbell JA, Xue Q-L, et al. 2022.. Effectiveness of social needs screening and interventions in clinical settings on utilization, cost, and clinical outcomes: a systematic review. . Health Equity 6::454–75
     [Crossref] [Google Scholar]
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Integrating Social Needs into Health Care: An Implementation Science Perspective
Annual Review of Public Health 46, 151 (2025); https://doi.org/10.1146/annurev-publhealth-071823-111332
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