ArticleJournal of primary care & community health
Addressing Social Determinants of Health Identified by Systematic Screening in a Medicaid Accountable Care Organization: A Qualitative Study.
Article in Journal of primary care & community health. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT06926855 (Community Health Workers Systematically Assessing and Addressing Social Determinants of Health to Improve Outcomes in Community Health Centers), which is not on this map. Cited by 29 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Community Health Workers Systematically Assessing and Addressing Social Determinants of Health to Improve Outcomes in Community Health Centers (CHW-SYSTIM)
Who cites it
29 citing papers in PubMed, 1 synthesis or guideline pooled it, 36 citations in OpenAlex.
- The Paradoxes of Social Care: Reframing Apparent Conflicts.Annals of family medicine · 2026Pooled it
- Changes in documentation of social risk factor diagnosis codes: comparison of Medicaid Accountable Care Organization model types.Health affairs scholar · 2026Article
- Health system-community partnerships in a Medicaid nutrition and housing program, 2020-2023: a mixed-methods evaluation.Health affairs scholar · 2026Article
- Screening for Health-Related Social Needs Among Inpatient Adults at an Academic Medical Center.Journal of general internal medicine · 2026Article
- Impact of Food Insecurity Resource Navigation for Primary Care Patients with Diabetes and Hypertension: A Matched Cohort Study.Journal of general internal medicine · 2026Article
- Under Pressure and Underrecognized: The Role of Social Workers and Case Managers in Screening for Social Determinants of Health in the United States.Journal of patient-centered research and reviews · 2026Review
- Screening for Social Determinants of Health in Patients With Systemic Lupus Erythematosus: A Point-of-Care Feasibility Study.Arthritis care & research · 2025Observational
- A multi-level framework for advancing digital health equity in learning health systems: aligning practice and theory with the Quintuple Aim.International journal for equity in health · 2025Article
- A Narrative Review on Shifting Practice and Policy Around Social Determinants of Health (SDOH) Screenings: Expanding the Role of Social Workers in Healthcare Settings in the U.S.Healthcare (Basel, Switzerland) · 2025Review
- Stakeholder perspectives on facilitators and barriers to implementing a zero-dollar copay program for chronic conditions study.Health research policy and systems · 2025Article
- Screening tools for employment in clinical healthcare delivery systems: a content analysis.BMC health services research · 2024Article
- Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations.Journal of general internal medicine · 2024Article
- Social determinants of health correlations and resource usefulness at a Milwaukee free clinic for uninsured individuals: A cross-sectional study.Journal of clinical and translational science · 2024Article
- Community Health Center Staff Perspectives on Financial Payments for Social Care.The Milbank quarterly · 2023Article
- Social Risk Screening and Response Equity: Assessment by Race, Ethnicity, and Language in Community Health Centers.American journal of preventive medicine · 2023Article
- Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.JAMA health forum · 2023Article
- Patients' Willingness to Accept Social Needs Navigation After In-Person versus Remote Screening.Journal of the American Board of Family Medicine : JABFM · 2023Article
- Pediatric primary care provider and staff perspectives on the implementation of electronic health record-based social needs interventions: A mixed-methods study.Journal of clinical and translational science · 2023Article
- Article
- Physician awareness of social determinants of health documentation capability in the electronic health record.Journal of the American Medical Informatics Association : JAMIA · 2022Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
6 authors at 2 institutions in 1 country.
Funding
Abstract
INTRODUCTION/
objectivesSystematic screening for social determinants of health (SDOH), such as food and housing insecurity, is increasingly implemented in primary care, particularly in the context of Accountable Care Organizations (ACO). Despite the importance of developing effective systems for SDOH resource linkage, there is limited research examining these processes. The objective of the study was to explore facilitators and barriers to addressing SDOH identified by systematic screening in a healthcare system participating in a Medicaid ACO.
methodsThis qualitative case study took place between January and March 2020. Semi-structured interviews were conducted with fifteen staff (8 community resource staff and 7 managers) from community health centers and hospitals affiliated with a large healthcare system. Interviews were transcribed, coded, and analyzed using the Framework Method.
resultsFacilitators for addressing SDOH included maintaining updated resource lists, collaborating with community organizations, having leadership buy-in, and developing a trusting relationship with patients. Barriers to addressing SDOH included high caseloads, time constraints, inefficiencies in tracking, lack of community resources, and several specific patient characteristics. Further, resource staff expressed distress associated with having to communicate to patients that they were unable to address certain needs.
conclusionsHealth system, community, and individual-level facilitators and barriers should be considered when developing programs for addressing SDOH. Specifically, the psychological burden on resource staff is an important and underappreciated factor that could impact patient care and lead to staff burnout.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.