Health Related Social Needs Screening and Referral Fulfillment: Toward a Complex Model.

Health Related Social Needs (HRSN) is an important driver of patient health outcomes. Healthcare organizations address patient HRSN with screening and community resource referral fulfillment (S&RF) processes for which they lack patient retention data, due to information silos. The process is complex and not fully represented in available conceptual models nor adequately assessed for effectiveness. The objective was to develop an evidence-based HRSN S&RF complex model and identify patient retention parameters. Model development drew from the literature and expert input to create a complex S&RF model, and identify parameters for model stages and factors. Studies (50) involved manual S&RF processes in small, specialized populations. The model organized 88 factors among five S&RF stages. Half the studies reported parameters, for which stage and factor ranges were wide and indicated reduced patient retention along the process. Needed is data from routine care in which HRSN platforms are used, and information silos overcome.