Tracy Kay



Bridging the Gap Between Medical Care and Social Needs

Primary investigator: Tracy Kay, MSN, RN

Purpose: This quality improvement (QI) project sought to evaluate the effectiveness of a screening tool for social determinates as well as the implementation of a referral process at Turning Point Medical Clinic (TPMC) for services offered.
Methods: The Social Screening Assessment and Referral (SScAR) project was a four-step process: (a) social needs screening, (b) clinician assessment, (c) referral, and (d) verifying follow-through. Retrospective chart review was conducted to collect baseline information on social screening prior to the implementation of the SScAR intervention. The clinic integrated the new assessment process during new patient intake interviews for patients ages 18 to 64 that fit the inclusion criteria. Data analysis compared the pre and post-intervention groups on the categorical outcomes using Chi-square analysis.Results: The study involved a total of 116 patients with 60 patients in the pre-intervention and 56 in the post-intervention. There were no significant differences between the groups for demographic variables. Participants in the post-intervention cohort were 12 times more likely to have an assessment and 6.6% higher rate of referral in comparison to the retrospective cohort. There were no differences between the two cohorts for the follow-up outcome or the time in days to follow-up.

Discussion: The results indicate that adoption of systematic process to evaluate, assess and refer participants in the pilot project were effective and beneficial to the study population. This quality improvement project demonstrated that having a system in place using staff to help in the screening and referral process improved patient outcomes. Unfortunately, there were no differences between the two cohorts for the follow-up outcome.

Conclusion: Using social screening tool for assessing a patient social need does assist in better patient outcomes. The SScAR project brought awareness to the providers of what social deterrents a patient may be facing and to introduces resources that could help address the needs. More research is need to investigate varied approaches in improving adherence to suggestion follow-up referrals. 


Major Professor: Dr. Susan Porterfield, PhD, FNP-C



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