Following up on food insecurity: Pragmatic barriers to measuring primary care screening and referral outcomes

of eight common SDOH domains, beginning in the emergency department (ED) and general pediatric mobile clinic, followed by outpatient pulmonology and endocrinology, inpatient wards, and a standing pediatric clinic.Each site determined their optimum workflow integration of the tool based on staffing and resources.We used descriptive statistics to report our findings.Results: Based on interviews, systemic pitfalls were (1) inconsistent reporting of social needs through a myriad of disparate SDOH screening mechanisms; (2) underutilization of collected SDOH data; (3) duplicative and siloed interventional design; (4) poor tracking of SDOH data for clinical use; and (5) inadequacies in intervention.A total of 419 families self-screened using the novel tool, with the majority (74%) accessing it in the mobile clinic.Seventy-three (17%) indicated urgent need, 50 (12%) non-urgent need, and 273 (65%) no need.Of those with urgent need, trouble paying bills, food insecurity, and a family member with mental health issues were most common.In this group, 77% completed a phone-based social work intervention within 3 days of screening.Most families rated high ease (96%) and comfort (68%) with self-screener completion. Conclusion:We demonstrate a collaborative approach to developing and implementing a workflow adaptable SDOH screening and intervention model across our healthcare enterprise that responds to common barriers of implementation.