Addressing Social Determinants of Health: Finally, Tools for Primary Care

Interviewer: Laurie Scudder, DNP, NP; Interviewee: Danielle Jones, MPH


October 10, 2018

Editorial Collaboration

Medscape &

The EveryONE Project is an ambitious strategy recently developed by the American Academy of Family Physicians (AAFP) that provides clinicians with practical, relevant tools to address social determinants of health (SDoH). It provides education and resources that support physicians in screening for SDoH, identifying resources in their communities, local advocacy, and collaboration with other professionals to advance health equity. Medscape spoke with Danielle Jones, MPH, manager of AAFP's Center for Diversity and Health Equity, about the resources provided by The EveryONE Project and practical strategies to incorporate them into practice.

Danielle Jones, MPH

Medscape: Addressing SDoH begins with knowing how they affect health, and the AAFP offers screening tools for use in the primary care setting. What are some strategies for incorporating these into routine practice without tying up significant amounts of the physician's time?

Jones: We always emphasize that family physicians do not have to do this work alone. It is important for them to be able to incorporate all members of the practice team. Each one of those individuals has contact with the patient from the time that he or she walks in the door to the time that they are making their follow-up appointment at the end. We looked to outline the things that individuals in each role can do during the patient encounter and how they can be provided with access to the resources that we have created.

Medscape: The Neighborhood Navigator allows clinicians to locate specific resources to address specific SDoH within their own communities. The site also can be used by patients. Have you seen it used more as a physician resource or a patient resource?

Jones: I think it is a blend of both. Certainly, we hope that the tools we have provided will better allow a family practice to capture SDoH data using the screening tool that we provide. That will allow improved identification of something that might be a real or potential risk. The practice staff—physician, nurse, technician—can then go into the Neighborhood Navigator and specifically search for a resource that would address that issue. Alternatively, during that patient encounter, the practice staff could choose to demonstrate for the patient how to access the resource on their own. So if that patient or family has the resources to be able to later go in and search for services independent of the physician-recommended ones, they can do so. We do see the use of the tool as appropriate for both practice and patient.

Medscape: What about patients and families who do not want to discuss their need for assistance with their clinician? Is there a way to provide this resource to patients without a discussion to identify their individual needs? For example, via signage in an office that would not require a reluctant patient to have a discussion about their circumstances?

Jones: Absolutely. It is not something that has to be accessed with the assistance of a physician. While we have not yet directly marketed the navigator to patients, once they become knowledgeable of its existence, they can access it independently, in consultation with other family members or resources outside of the healthcare system. One of the things that we have created in addition to the screening tool is a patient form that an individual can leave with after the visit with the physician. We hope that this will allow a patient and family to look at the things that they have identified on that form and then access the information out in the community on their own.

Medscape: AAFP pilot-tested these tools with a number of family physicians. What were some of the key things you learned that you want to pass on to the broader family medicine community?

Jones: All of our resources are definitely developed with the input and feedback of our membership. Some of them were already using screening or referral resources before we began to develop ours. And that helped us to determine content that we needed to include. What we heard from our members who pilot-tested these tools was that this was the first time they actually had a tailored resource. There is a lot of excitement about organization-wide, systematic integration of these resources, even with those members who had already been doing something in their practices. The EveryONE Project tools provide a focus that is specifically tailored for primary care and family medicine.


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