Date of Award

January 2023

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

Mary Ann Camilleri


Social risk factors, the social determinants of health associated with negative health outcomes, drive patient-level social needs that contribute to health inequalities, high medical cost, overutilization of services, and have a greater impact on morbidity, mortality, and quality of life than chronic diseases (Krist et al., 2020). While there seems to be a consensus on the importance of addressing social factors, most health systems lack the infrastructure to develop the screening and referral protocols required to address social needs (Alley et al., 2020). Primary care has been identified as a key setting to introduce strategies around identifying at-risk patients with social needs and linking them to community resources as they are typically the first point of health care access for most people (Valaitis et al., 2020). The goal of this project was to develop screening processes and workflows in primary care settings to connect patients to community resources using care navigational resources. A 10-week pilot was conducted at two practices. The implementation of screening tools, workflows, and referrals pathways were evaluated to understand the model’s impact on care delivery and to make recommendations for scaling the processes to other practice sites. A total of 150 patients were screened, and 71 patients reported to having at least one social need. The importance of addressing social needs within insured populations was highlighted with nearly half of the patients screening positive. Providers were surveyed post-implementation using a five-point Likert scale questionnaire. They expressed positive overall feelings about the process. The project supports that integrating social factors into the provision of care moves practices towards the realization of whole-person care for the promotion of health and wellbeing


This is an Open Access Thesis.

Open Access

This Article is Open Access