ArticleBMJ open2021
Scaling-up social needs screening in practice: a retrospective, cross-sectional analysis of data from electronic health records from Bronx county, New York, USA.
Article in BMJ open, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 19 papers, 1 of them a synthesis that pooled it.
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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.
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Who cites it
19 citing papers in PubMed, 1 synthesis or guideline pooled it.
- The Paradoxes of Social Care: Reframing Apparent Conflicts.Annals of family medicine · 2026Pooled it
- Social Needs Screening and Subsequent Acute Care Utilization in a Large Safety-Net Health System: A Retrospective Cohort Study.Journal of general internal medicine · 2026Article
- Epidemiology of Health-Related Social Needs Screening and Positivity in a Multistate Health System.JAMA network open · 2026Article
- Article
- A multidimensional framework for mapping social need to electronic health records in people with multimorbidity.Scientific reports · 2026Article
- Fewer screens, greater needs: housing insecurity and healthcare costs for transgender patients in a safety-net system.Health affairs scholar · 2026Article
- Integration of Interprofessional Education Into Routine Resident Practice: 2 Cases of Successful Implementation.Journal of graduate medical education · 2025Article
- Health-related social needs screening, reporting, and assistance in a large health system.Preventive medicine · 2025Article
- Universal Cardiovascular Disease Risk Assessment in Pregnancy: Call to ActionJACC. Advances · 2024Review
- Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York.BMC primary care · 2024Article
- Patients with unmet social needs are at higher risks of developing severe long COVID-19 symptoms and neuropsychiatric sequela.Scientific reports · 2024Article
- Understanding individual health-related social needs in the context of area-level social determinants of health: The case for granularity.Journal of clinical and translational science · 2024Article
- Health-Related Social Needs: Which Patients Respond to Screening and Who Receives Resources?Journal of general internal medicine · 2023Observational
- Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system.Journal of clinical and translational science · 2023Article
- Pediatric emergency department organization and social care practices among U.S. fellowship programs.AEM education and training · 2022Article
- Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System.Journal of primary care & community healthArticle
- Addressing Health-Related Social Needs in Hospitalized Children: An Implementation Assessment.Academic pediatricsArticle
- Implementing Health Related Social Needs Screening in an Outpatient Clinic.Journal of primary care & community healthArticle
- Cross-Sectional Analysis of Insurance Claims Shows Health Care Utilization and Costs Associated With Health-Related Social Needs (HRSNs) in an Urban Population.Journal of primary care & community healthArticle
Corrections and comments
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Authors and funding
10 authors.
Funding
Abstract
objectivesThere has been renewed focus on health systems integrating social care to improve health outcomes with relatively less related research focusing on 'real-world' practice. This study describes a health system's experience from 2018 to 2020, following the successful pilot in 2017, to scale social needs screening of patients within a large urban primary care ambulatory network.
settingAcademic medical centre with an ambulatory network of 18 primary care practices located in an urban county in New York City (USA).
participantsThis retrospective, cross-sectional study used electronic health records of 244 764 patients who had a clinical visit between 10 April 2018 and 8 December 2019 across any one of 18 primary care practices.
methodsWe organised measures using the RE-AIM framework domains of reach and adoption to ascertain the number of patients who were screened and the number of providers who adopted screening and associated documentation, respectively. We used descriptive statistics to summarise factors comparing patients screened versus those not screened, the prevalence of social needs screening and adoption across 18 practices.
resultsBetween April 2018 and December 2019, 53 093 patients were screened for social needs, representing approximately 21.7% of the patients seen. Almost one-fifth (19.6%) of patients reported at least one unmet social need. The percentage of screened patients varied by both practice location (range 1.6%-81.6%) and specialty within practices. 51.8% of providers (n=1316) screened at least one patient.
conclusionsThese findings demonstrate both the potential and challenges of integrating social care in practice. We observed significant variability in uptake across the health system. More research is needed to better understand factors driving adoption and may include harmonising workflows, establishing unified targets and using data to drive improvement.
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