Article Figures & Data
Tables
System Level Activity Integrated Primary Care Strategy Awareness: Activities that identify the social risks and assets of defined patients and populations. Routine screening of social needs
Formal and informal team communication (eg, electronic health record templates, flow sheets and best practice alerts; team huddles; warm handoffs and informal conversations)
Assessment of patient priorities
Adjustment: Activities that focus on altering clinical care to accommodate identified social barriers. Evaluate structural and patient-level barriers
Shared decision making to develop action plan
Respect patient preference for which team member the patient meets with and how often
Options for intervention modality (in-person; text; telehealth)
Assistance: Activities that reduce social risk by providing assistance in connecting patients with relevant social care resources. Functional workflows for responding to identified needs
Initiate response during the visit
On-site provision of intervention to address social need (preferable) or active connection of patient to community resource
Alignment: Activities undertaken by health care systems to be aware of and connect with existing social care assets in the community, organize them to facilitate synergies, and invest in and deploy them to positively affect health outcomes. Development of shared agenda across the practice
Staff training
Clear delineation of roles and responsibilities
Team meetings and huddles
Patient education materials describing team member roles
Relational continuity
Follow-up to re-assess and recalibrate plan
