Linking Underserved Patients to Social Services Using the SScAR Tool.

Background: The need to screen for social determinants of health (SDOH) is well documented in the literature. Addressing SDOH also requires linking patients to available social service resources.

Objective: This Social Screen Assess and Refer (SScAR) Quality Improvement (QI) project purpose was threefold: (1) develop an agency specific tool to screen for SODH; (2) implement this tool in all new patient evaluations; and (3) provide referral to patients for necessary social services.

Methods: The SScAR tool adapted questions from published screening tools and created new questions centered on available social services. A pilot study implemented the tool. Documentation of social needs before the pilot, SScAR utilization during the pilot, number of social needs, and referrals made were measured.

Results: Documentation of SDOH screening significantly improved with the tool (α .05, χ²(1) = 21.85, p < .001). Follow-through referral to specific social resources only increased by 5%.

Conclusions: The SScAR is a feasible tool for identifying SDOH needs and creates a mechanism for linking patients with social services.

Implications for nursing: Future studies must measure social service referrals, utilization of social services, and the resulting impact on specific health outcomes such as blood pressure, hemoglobin A1c, and cholesterol.