Table 4.

Article Outcomes by Included RE-AIM Categories (Reach, Adoption, Implementation, and Maintenance) (n = 42)

Author, Year	Outcomes
	Reach outcomes (n = 7)
Bittner et al., 2021³¹	Patients who were identified as Non-Hispanic White had higher rates of completed screens; patients classified as “Other/unknown” race/ethnicity had lower rates of completed screens. Medicaid-insured patients with completed screens were more likely to be Hispanic/Latino or Non-Hispanic Black.
Bleacher et al., 2019³²	Although patients identified as AA race made up 13% of patients eligible for screening, they made up only 11% of those screened; versus patients identified as White made up 60% of the screening eligible population but 62% of those screened.
Cottrell et al., 2019³³	A greater proportion of Hispanic patients were screened for social risks (32% vs 25% of patients not screened).
Fiori et al., 2021³⁴	Patients who received care at a practice with a CHW focusing on social service support were more likely to be screened as compared with practices without a CHW or a CHW not focused on social service support (29% vs 15% and 13%, respectively). 26% of active pediatrics patients, 20% of internal medicine patients and 19% of family medicine patients were screened.
Freibott et al., 2021³⁵	Hospital 1: 271/289 94% patients asked to participate were screened; 28/271 (11%) declined to answer need-based questions; 100% of patients were screened at Hospital 2 to 4.
Gold et al., 2018³⁶	At one clinic site (B), a greater proportion of patients identified as Hispanic were screened, compared with the clinic patient population. At another (site C), a greater proportion of patients identified as Asian race were screened. Across all clinics, a lower proportion of patients who prefer to speak Spanish were screened compared with patients preferring to speak English.
Murray et al., 2022³⁷	In the pre-COVID period, 666/16,674 potentially eligible patients were screened in person, and 592/11,309 potentially eligible patients were screened in ED by phone in the post-COVID period. Potentially eligible = patients with Medicaid/Medicare insurance (target population) who were seen in the ED during the study period.
	Adoption outcomes (n = 13)
Beck et al., 2012³⁸	Indirectly evaluated clinician screening practices.^* 81% of caregivers had 1/7 social history questions documented; >50% had all 7 social history questions documented (mean 4.5 questions).
Buitron de la Vega et al., 2019³⁹	Indirectly evaluated healthcare team screening practices. Among 85/1696 patients screened on a paper screener instead of directly on an EHR-embedded tool, 75% were integrated into the electronic health record (EHR) by medical assistances. 82% of patients who screened positive on the social screener had ICD-10 codes added to their visit diagnoses (367/445).
Colvin et al., 2016⁴⁰	Indirectly evaluated clinician screening practices. Intervention interns who received training on social screening using behavioral change strategies (e.g. reminders/cues to screen) included information on patients social risks in their admission history and physicals (H&P) for 82% of their inpatient pediatric patients versus 17% in the control group.
Fiori et al., 2019⁴¹	Indirectly evaluated clinician screening practices. On average, 76% of providers had patients screened during well-child visits over an 11-month period (engaged = >50% of eligible patients were screened).
Fiori et al., 2021³⁴	Indirectly evaluated clinician screening practices. Active clinician participation in social screening was defined as whether social screener results were present in a patient note in the EHR. Screening participation varied among clinicians: 13% of clinicians had social screener results documented in 1 to 5 patient notes over the study period. Pediatric providers were the largest proportion of clinicians actively participating ins screening (55%), followed by internal medicine (49%) and family medicine clinicians (49%).
Higginbotham et al., 2019⁴²	Indirectly evaluated staff screening practices. Staff administered screening was completed for 63% of patients/families overall; screening rates varied from 68% week 1, 45% week 2, 77% week 3.
O'Toole et al., 2013⁴³	Directly evaluated clinician screening practices. After intervention training, intervention residents screened patients more frequently for familial support, utility issues, and housing conditions (based on direct observation).
Patel et al., 2018⁴⁴	Indirectly evaluated clinician screening practices. An intervention to increase resident screening (trained residents on screening and local resources; included visual reminders to screen) increased documentation of screening in patient notes for two domains, income and housing.
Power-Hays et al., 2020⁴⁵	Indirectly evaluated healthcare team screening practices. A quality improvement project to increase the number of completed social screening surveys found that the percentage of completed screenings varied per month from 23% (attributed to short staffing) to 89% at its highest (attributing to changing the responsibility of distributing the social screened from the clinician to the clinical assistant).
Sand, 2021⁴⁶	Indirectly evaluated clinician screening practices. An intervention to train clinicians increased the number of documentations of social screening post-intervention from 44% (n = 16) to 93% (n = 39) of new patient visits.
Schwartz et al., 2020⁴⁷	Directly evaluated clinician screening practices. 29% of hospitalists and 41% of nurses (RNs) reported frequently screening hospitalized patients for 1+ social risk; 97% of hospitalists and 65% of RNs reported not using a specific screening tool.
Silva et al., 2021⁴⁸	Indirectly evaluated clinician screening practices. Comparisons of screening percentages and patient populations between clinician groups: 91% of families seen by residents were screened for 1+ SDH (95% CI: 88.4% to 93.4%) versus 96% of faculty patients (95% CI: 94.3% to 98.2%). Families were screened less frequently for food insecurity and financial insecurity by residents compared with faculty (79.3% vs 92.5%, P < .05; 79.9% vs 93.6%, P < .05; respectively). A similar percentage of families were screened for school absence by residents and faculty (83.9% and 86.1%, P = .78).
Vasan et al., 2020⁴⁹	Directly evaluated clinician screening practices. More residents reported screening within outpatients settings compared with inpatient settings.
	Implementation outcomes (n = 32)
Berry et al., 2020⁷²	Facilitators/Adaptations: Screens increased after integrating screening into existing workflow. Each clinic modified a tool adapted to their workflow and patient population.
	Barriers: Staff burden (one site switched to using volunteers); lack of time to discuss screening results with patients; patient literacy, limited English proficiency, concerns about immigration status, screening fatigue.
Bleacher et al., 2019³²	Facilitators: Practice-wide data sharing on screening rates increased screening activities. Using multiple communication strategies (email, meetings daily huddles) helped to communicate about screening. A physician champion helped increase awareness about the importance of screening and progress screening efforts. Concerns about lack of time to screen declined during pilot screening implementation.
Broaddus-Shea et al., 2022⁶⁸	Facilitators: Frame screening as standard and not singling out patients; normalize social needs; assure patients about privacy; clarify purpose of screening; describe relationship between social needs and health; emphasize benefits to the community; respect patient autonomy; build trusting relationships; treat screening as ongoing process; draw on trauma-informed care; offer resources first; understand and acknowledge social and structural barriers to assistance.
	Barriers: Lack of framing/introduction of screening; lack of time to follow up with patients after positive screens. Concerns about confidentiality.
Browne et al., 2021⁶⁹	Barriers: Managers noted that patients had difficulty completing screening before their appointments due to discomfort with technology and lack of time.
Buitron de la Vega et al., 2019³⁹	Time: Medical assistants (MAs) took an average of 1 minute to enter responses from screening into patients' EHR.
Byhoff et al., 2017⁷⁰	Adaptations: 41% of health centers reported that screening was self-reported. Most commonly “other” staff were reported as screening patients (24%), followed by MAs (22%); social workers/ case managers (18%); providers (16%); front desk (12%); RNs (10%). 40% of screening was conducted before, during, or after a visit; new patients were most frequently targeted; most health centers (63%) used the EHR to record social information directly.
Chisolm et al., 2019⁷¹	Adaptations: Lack of social risk data standardization across clinics made it difficult to use it to evaluate for health disparities.
Drake et al., 2021⁶⁵	Facilitators: Clinicians reported that specific, evidence-based patient engagement techniques, such as empathic communication and motivational interviewing, facilitated implementation and delivery of the screening assessment. Patients appreciated not feeling rushed and acknowledged the benefit of empathic communication with healthcare team.
	Barriers: Clinicians noted that EHR documentation could be time consuming. It was unclear who should conduct screening. Time was a barrier to screening efforts.
Drake et al., 2021⁶⁶	Cost: The study estimated costs of social care programs at 4 FQHCs; costs included referral and case management activities beyond screening. Variability in program costs between FQHCs was attributed to personnel cost. Adaptation: There was variability in screening activates across FQHCs, including the use of customized EHR flowsheets.
Emengo et al., 2020⁶⁷	Facilitators: Caregivers preferred to receive the screening survey while waiting for a visit (to make best use of time); caregivers expressed a preference for trained navigators vs physician to screen due to a perception that navigators had more time. Caregivers appreciated when their clinicians were aware of the screening results.
Fiori et al., 2019⁴¹	Facilitators: Developed a standardized process for screening during well-child visits. A ‘provider champion'--a designated clinician based at the health center who led ongoing program quality improvement--was used to coach community health workers (CHWs), and lead program adaptions. ‘Administrative liaisons'--clinical site leaders engaged with the program--provided overall leadership, direction, and supervision. Clinic met regularly to review progress and concerns, and make changes as needed.
Freibott et al., 2021³⁵	Facilitators: Having a short, easy to use screening tool.
	Barriers: Lack of a standardized referral process made screening difficult to sustain or justify.
	Adaptations: Hospitals were given flexibility regarding who/when/how to screen.
Garg et al., 2007⁶⁰	Facilitators: Caregivers in intervention group (residents trained to screen caregivers) discussed a greater number of family psychosocial topics (2.9 vs 1.8) with their resident clinician and had fewer unmet desires for discussion (0.46 vs 1.41) compared with caregivers in control arm.
	Time: 91% of residents reported screening added <5 minutes to the visit and 55% of residents reported screening added <2 minutes to their visits.
Godecker et al., 2013⁶¹	Facilitators/Workforce: CHWs were able to capture more social risk information compared with RNs (patients disclosed more risks).
	Cost/Workforce: CHWs were able to conduct screening at 56% reduced costs compared with RNs.
Gold et al., 2018³⁶	Facilitators: Workflow customization, based on barriers encountered during implementation of screening/EHR documentation, facilitated expanding screening. Having an EHR-savvy clinic champion at each site facilitates screening/documentation efforts; served as a resource to screening implementation. Embedding social screening within the EHR facilitated screening.
	Barriers: Paper based screening created an extra step for staff to input screening. The EHR social risk tool was perceived by some as contributing to social risk data being in multiple places in EHR. Other barriers included: lack of staff EHR expertise/competencies, the tool needing to be customized at each site, differences in EHR security access by staff role.
Gottlieb et al., 2014⁶²	Facilitators/Modality: Caregivers who responded to computer-based survey versus face-to-face had higher disclosure of interpersonal violence/threats in the home, financial strain, child's safety, lack of/inadequate health insurance, income, and overall number of positive social risk domains.
Greenwood-Ericksen et al., 2021⁶³	Facilitators: Standardized screening to avoid missing important needs and standardize comparisons across subgroups; CHW roles (patients more willing to talk to CHWs, but CHWs also had limited time).
	Barriers: Not using evidence to select tools; time constraints; inconsistencies in practices; having to add in paper screens to EHR. Funding often determined who was screened (i.e. what patients were targeted).
	Adaptations: All FQHCs tailored screenings for specific subgroups, but details not provided. There was significant variability within and across sites regarding who screened, how and when screening was done, whether screening tools with integrated within EHR.
Higginbotham et al., 2019⁴²	Facilitators: Hypothesized facilitator to increasing adoption was having screening in brightly colored folders and easily accessible to staff.
Jones et al., 2021⁶⁴	Adaptation: Highlighted variability in clinician screening practices. More than 1/3rd of providers noted using informal practices to screen for social risks, asking questions differently depending on the client and family. Close to 50% reported using paper or electronic self-complete screening tools; face-to-face screening was less common.
Kim et al., 2021⁵⁸	Facilitators: Primary Care Liaison (PCL) educated 61 interprofessional primary care providers/staff on how to identify and refer patients to address unmet social needs. PCL provided way to screen patients for social needs after hospitalization.
Kocielnik et al., 2019⁵⁹	Facilitators/Modality: Low health literacy participants preferred using a Chatbot over online version of survey (Chatbot was perceived as engaging and caring) versus high literacy patients preferred online survey (Chatbot was perceived as robotic, disingenuous). Some participants reported being more comfortable disclosing social risks to a Chatbot versus others felt more comfortable disclosing on online survey; not split by literacy level.
	Time/Modality: The Chatbot took longer to complete than the survey for both high and low literacy patients.
LaForge et al., 2018⁵⁶	Adaptations: All organizations noted significant flexibility in who administered screening and when screening was done. Two organizations noted making changes to their tools after piloting; Kaiser's YCLS tool was shortened and translated into different languages; Mosaic Medical discontinued using their own screening tool for OCHIN's screening tool after 2 years.
Morgenlander et al., 2019⁵⁷	Barriers: Lack of time (68%), resources (50%), and training to administer and address positive screens (47%). 9% reported inadequate evidence as a barrier.
	Adaptations: Clinics used validated screening instruments (31%), instruments developed by the staff (28%), or adaptations of validated instruments (16%). Most surveys were administered by paper forms (55%), done at well visits (47%), and done by the primary care provider (51%).
O'Toole et al., 2013⁴³	Time: Intervention residents spent more time screening for social risks (median increase of 165 seconds vs control residents median increase of 30 seconds).
Oldfield et al., 2021⁵³	Time: Surveys were administered via tablet and took caregivers 5.6 minutes to complete versus 3.9 minutes for adolescents.
	Adaptations: Most screens took place during well-child preventive visits versus follow-up or urgent visits.
Page-Reeves et al., 2016⁵⁴	Facilitators: Patients who completed screen with MA face-to-face had higher rates of screening positive for social risks.
Palakshappa et al., 2021⁵⁵	Facilitators: Healthcare teams thought the mobile system aligned with how they thought screening should be done, and providers perceived the system as easy to use. Sent automated message in EHR to notify clinician seeing patient and clinic's patient navigator if they screened positive.
	Barriers: 43/219 (19.6%) patients required assistance with the tablet to complete tool; relied on study coordinator to assist patients if needed assistance completing screening.
Power-Hays et al., 2020⁴⁵	Facilitators: Changing responsibility of survey distribution from physician to clinical assistants; sharing data at staff meetings on high patient needs and patient satisfaction; giving screener to all patients for non-sick/non-urgent visits; posting reminders in exam rooms.
	Barriers: Temporary staff shortages.
Schwartz et al., 2020⁴⁷	Facilitators: Hospitalists reported doing more screening if they felt that screening was clinically relevant (e.g. there were concerns about language barriers, access to health care, insurance, transportation barriers, abuse, parent education/literacy), and doing more screening if they felt more competent at it.
	Barriers: Lack of time, resources, and a standardized inpatient social screening tool.
Sokol et al., 2021⁵²	Facilitators: Having systematic screening as part of workflow (e.g. through EHR checkbox); clinician involvement with screening process to build patient trust. Desire for explicit processes for screening frequency and screening rationale to provide transparency for families.
	Barriers: Time.
Wallace et al., 2020⁵⁰	Barriers: Staff expressed discomfort asking questions they believe to be stigmatizing.
	Fidelity: Staff used their own judgement to determine who to screen and how (which could be based on patient appearance or insurance type).
Wallace et al., 2021⁵¹	Facilitators: Patients noted that the perceived sincerity of screening staff impacted their receptivity to screening. Barriers: Staff noted discomfort with screening and perception of screening futility. Patients expressed concerns about stigma and privacy.
	Fidelity: Staff would tailor the screening using their “professional intuition;” decide how to frame screening/when to screen based on this intuition (including based on patient appearance).
	Maintenance outcomes (n = 1)
Colvin et al., 2016⁴⁰	30/43 intervention interns (70%) stopped using the screening tool during the maintenance period, whereas 13 (30%) continued screening until the end of the 21-month post-intervention period.

↵* Studies on adoption that are listed as having indirectly evaluated screening practices evaluated the number/proportion of clinicians/staff who conducted screening by analyzing the number/proportion of patient notes with documented screening results or number of completed screens.
Abbreviations: AA, African American; CHWs, community health workers; RN, registered nurse; ED, Emergency Department; EHR, Electronic health records; ICD-10 codes, International classification of diseases codes (10th Revision); CI, confidence interval; FQHCs, Federally qualified health centers.