Evidence-Based Best Practice Toolkit for Social Determinants of Health: A Program Evaluation Review

Despite an increase in healthcare expenditure, racial and ethnic disparities remain a substantial concern among adult primary care patients in the United States. This is largely due to the focus on medical intervention and disregard for the underlying factors that contribute significantly to health outcomes such as economic stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. The PICOT question that guided this program evaluation review project is: In adult clients seeking care at a primary care clinic (P), how does a SDOH toolkit based on the CDC framework (I) compared to no SDOH toolkit (C) affect identification of unmet health related social needs (O)? The evidence suggests that screening for SDOH identifies unmet social needs, improves provider referrals to relevant resources, and improves overall health outcomes. In addition, the literature supports the use and development of nursing toolkits to influence evidence-based interventions in healthcare. A detailed and thorough program evaluation review of the Centers for Disease Control and Prevention, Healthy People 2030, and the Health Leads Network SDOH programs revealed that the evaluated SDOH programs meet the requirements of a program per the CDC Program Evaluation framework. Additionally, the evidence supported the use of these programs as established to support the development of an SDOH screening toolkit for the specialty population of adult primary care patients. Screening for SDOH in adult primary care is a necessary component for improving health outcomes and use of an SDOH screening toolkit in the clinical practice setting will help assist in the smooth and successful implementation of SDOH screening for all adult primary care patients. PROGRAM EVALUATION TOOLKIT 4 Evidence-Based Best Practice Toolkit for Social Determinants of Health: A Program Review “Social determinants of health (SDOH) are defined as the constructs in which people are born, live, learn, work, play, worship, and age (Healthy People 2030, n.d.). SDOH are highly influential factors for the health and wellness of individuals across the globe. These circumstances are shaped by the distribution of money, power, and resources at the local, national, and global levels (Healthy People 2030, n.d.). Socially determined circumstances and social position can negatively impact an individual’s opportunity to attain their full health potential. Underlying factors such as poverty, unequal access to healthcare, lack of education, stigma, and racism contribute to health inequities (Tikannen & Abrams, 2020). The purpose of this DNP program evaluation review project was to search and evaluate current evidence on best practice for assessing SDOH. In addition, this paper evaluated the Centers for Disease Control and Prevention (CDC), Healthy People 2030, and the Health Leads network current SDOH screening programs and position statements to make recommendations based on evidence utilizing the CDC’s Program Evaluation framework (PEF). Finally, following evaluation of best practices and analysis of the existing programs, this project includes an up to date and relevant SDOH toolkit which includes a position statement, policy statement, screening tool examples, and current education materials for varied audiences. Significance of the Practice Problem Addressing social determinants of health is the only way to achieve health equity (Centers for Disease Control and Prevention, 2019). Despite an increase in healthcare expenditure, racial and ethnic disparities remain a substantial concern. The United States spends more on healthcare compared to other high-income countries yet has worse health outcomes. This is largely due to the focus on medical intervention and disregard for the underlying factors that contribute significantly to health outcomes (Tikannen & Abrams, 2020.). PROGRAM EVALUATION TOOLKIT 5 According to the Organization for Economic Co-operation and Development (OECD), (n.d.) the United States spends nearly twice as much on healthcare compared to other high-income countries. This is especially alarming because the U.S. has the lowest life expectancy and highest suicide rates among other high-income countries. In 2017, the average American’s life expectancy was 78.6 years which is two years lower than the OECD average life expectancy. Despite an increase in healthcare expenditure, racial and ethnic disparities remain a substantial concern. Non-Hispanic white Americans live an average of 78.8 years compared to non-Hispanic black Americans who live an average of 75.3 years (Tikannen & Abrams, 2020.). The United States has seen a dramatic decrease in infant mortality during the past eight decades; however, African American infants are 2.3 times more likely to die compared to a white infant (11.4 vs. 4.9 per 1000 births) (Singh et al., 2017). “Racial/ethnic, socioeconomic, and geographical disparities are marked by increased morbidity and mortality from cardiovascular disease, cancer, diabetes, COPD, HIV/AIDS, homicide, psychological stress, hypertension, smoking, obesity, and access to quality health care (Singh et al., 2017, p.1942).” The U.S. has the highest chronic disease burden with onequarter of adult Americans having been diagnosed with one or more chronic conditions. Obesity is highest among English speaking countries. Factors that contribute to obesity include unhealthy living conditions, socioeconomic and behavioral factors, and decreased access to quality food and nutrition (Tikannen & Abrams, 2020.). According to the Robert Wood Johnson Foundation (2014) one-fifth of all American children live in poverty and nearly 50% of all black children live below the poverty line. Twenty percent of Americans live in communities with limited job opportunities, high rates of pollution, limited access to healthy food, poor housing conditions, and reduced opportunity for physical activity. By 2043, most Americans will be people of color; however, people of color disproportionally suffer due to economic disadvantages and have worse health outcomes caused by preventable reasons. PROGRAM EVALUATION TOOLKIT 6 Communication deficits surrounding SDOH are a major cause for concern. Racial and cultural differences have resulted in distrust and poor communication, especially amongst black Americans and minorities (Butler & Sheriff, 2021). Poor communication reflects the shortcomings of the American health system and inhibits the goal of obtaining equitable care for all people. The field of medicine places major emphasis on behavioral modification as the main strategy for disease and illness prevention (Andermann & CLEAR Collaboration, 2016). This approach has not proven to be the most effective strategy as individuals are not likely to be in control of health-related social factors that are contributing to their poor health outcomes (Andermann & CLEAR Collaboration, 2016). Broader interventions such as creating more supportive environments are necessary for reducing unhealthy behaviors and supporting healthy choices. Widespread adoption of the electronic health record (EHR) has led to the creation of the Promoting Interoperability Programs (PIP) by the Centers for Medicare and Medicaid services (Chen et al., 2020). Stage three of the PIP involves the use of the EHR to demonstrate continuous quality improvement of care and elimination of healthcare inequality across all groups of people. The number of healthcare institutions that are exploring ways to capture SDOH data, referrals, and interventions to meet the needs of vulnerable populations is on the rise. Adoption of an SDOH toolkit is helpful for minimizing pitfalls and overcoming barriers to screening and treating for health-related social factors affecting patient outcomes. Purpose of the Program Evaluation Project The purpose of the program evaluation review project was to evaluate three professional organizations and their current SDOH screening programs according to best practices so that recommendations could be made for improvement. Secondly, by evaluating existing toolkits in practice for currency and relevance, a new toolkit was developed for the specialty population of adult patients in primary care. The newly developed toolkit more accurately represents the PROGRAM EVALUATION TOOLKIT 7 evidence related to reducing SDOH risks that contribute to poor adherence to health measures in at risk populations. The population of interest includes adults over age 18. The setting includes primary care clinics and any organization that supports the population of interest. The intervention includes an SDOH toolkit that was derived from evaluation of existing toolkits. In addition, the CDC’s PEF served as the guide for the evaluation of the three professional organizations or government agencies so that recommendations for change could be made. Project Objectives The objectives of this project have been outlined using the SMART format (specific, measurable, attainable, realistic, and timed) and are as follows: 1. The project manager (PM) will identify three professional organizations or government agencies current social determinants of health screening program by the end of week 5 of the project proposal development period. 2. Using the CDC’s program evaluation framework, the PM will make at least two recommendations through practice/position statements by the end of week four of the project proposal development period. 3. The PM will develop a social determinants of health toolkit to include an updated position statement, policy statement, screening tool examples, and current education materials for varied audiences by the end of week four of NUR7803. Program Problem Statement The PICOT that guided the development of this program evaluation review project is: In adult clients seeking care at a primary care clinic (P), how does a SDOH toolkit based on the CDC framework (I) compared to no SDOH toolkit (C) affect identification of unmet health related social needs (O)? The population of interest includes adults over age 18. The setting includes primary care clinics and any organization that supports the population of interest. Despite a growing interest in capturing data surrounding SDOH and the effects on health outcomes, there was a lack of an effective toolkit to conduct SDOH screening in primary care. PROGRAM EVALUATION TOOLKIT 8 Utility of Program Review Evidence-based toolkits improve healthcare and facilitate practice change to a variety of audiences (Barac et al., 2014). They often include useful materials such as implementation guidelines, participant training, and audit materials which are presented in a variety of formats (Yamada et al., 2015). A definitive toolkit for SDOH screening was not located within the literature. Relevant stakeholders for the program evaluation, analysis, and the development of the SDOH screening toolkit include: health practitioners, patients, community and health organizations, policy makers, and members of the public. Reviewing SDOH programs through the lens of stakeholders is valuable because it provides insight into the values and perspectives on the program’s objectives, operations, and outcomes (CDC, 2017). Primary care is the setting that was most influenced by completing the program change because this setting most supports the population of interest. The American Academy of Family Physicians (AAFP) reports that screening for SDOH in primary care is critical because primary care is a natural point of integration amongst other forms of healthcare (public health, behavioral health, and community-based services) (AAFP, 2022). Fifty-one percent of adults in the United States made a visit to a primary care physician in 2019 (CDC, 2021). Based on this, screening for SDOH at primary care visits has the capacity to reach vulnerable patients to provide them with the support they need to improve their health outcomes. Thus, the evaluation, analysis and revision will improve current conditions by ensuring that practice/position statements are in alignment with what the literature suggest as best practice and using the CDC’s PEF. Analytical Framework Program evaluation holds healthcare organizations accountable and committed to improving health outcomes. The CDC’s PEF is a six-step process and is as follows: 1. Engage stakeholders 2. Describe the program PROGRAM EVALUATION TOOLKIT 9 3. Focus the evaluation design 4. Gather credible evidence 5. Justify conclusions 6. Ensure use and share lessons learned. Each step is interdependent but must be fulfilled to facilitate an accurate understanding of the program’s context (CDC, 2017). Further discussion of each step provides a structured way to review a program and understand the standards for program effectiveness. Engage Stakeholders The evaluation cycle began by examining those individuals or organizations that will be affected by what was learned from the evaluation and what will be done with the knowledge. The principal groups of stakeholders include those involved in program operations, those served or affected by the program, and the primary users of the evaluation. (CDC, 2017). During this step of the framework, the PM gained a better understanding of the stakeholders’ values and perspectives on important elements such as the program’s objectives, operations, and outcomes. Describe the Program Detailed program descriptions were necessary to convey the mission, goals, and objectives of the program being evaluated. A complete program description should include information about the programs need, expected effects, activities, resources, stage of development, context, and logic model (CDC, 2017). Program descriptions were useful during the program evaluation project to compare the program to similar programs. In addition, it helped to facilitate the connection between the program and its effects on healthcare. Focusing the Evaluation Design The standards for effective evaluation include utility, feasibility, propriety, and accuracy (CDC, 2017). These standards were met by planning the direction of the evaluation in advance. The PM utilized this step of the framework to clarify the intent of the evaluation, identify how the PROGRAM EVALUATION TOOLKIT 10 results of the evaluation were to be used, and to develop practical methods for data collection, analysis, and interpretation. Gather Credible Evidence A successful and credible evaluation is one that collects information that produces an accurate depiction of the program in its entirety. Credible evidence provides for subsequent strong evaluation judgments and recommendations for change (CDC, 2017). During this stage of the framework evaluation, the PM identified indicators which served as a basis for measuring meaningful effects of the program (i.e.: ability to deliver services, client satisfaction, resource efficiency, etc.). Justify Conclusions Evaluation of conclusions can only be justified when they have been linked to the evidence gathered and when they have been compared to agreed upon benchmarks set by the stakeholders (CDC, 2017). This process required standards, analysis and synthesis, interpretation, judgement, and recommendations. The standards served as a basis for developing judgments about the program’s performance success. Analysis and synthesis pinpointed patterns and findings about the evidence gathered. Interpretation was useful for understanding the significance of the information learned during the project evaluation. Judgements were made about the significance of the program by comparing the findings to other pre-selected standards. Finally, the recommendation to continue, expand, redesign, or terminate a program was based on evidence and stakeholder values. Ensure Use and Share Lessons Learned The ensure use and share lessons learned phase of the framework involves the translation of evaluation findings into practice. The purpose of this step was to ensure that the evaluation achieved its primary purpose (CDC, 2017). Thus, the PM described the essential features of the program, defined the focus of the evaluation and any limitations, identified the strengths and weaknesses, and discussed any recommendations for action. PROGRAM EVALUATION TOOLKIT 11 Evidence Search Strategy, Results, and Evaluation The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed database were searched using the following Boolean operator, (social determinants of health) AND (social determinants of health screening tool). Key terms include social determinants of health, health equity, health inequality, health disparity, health risk assessment, and social determinants of health screening tool. An additional CINAHL search was performed with the following Boolean operator, nursing AND toolkit AND best practice. Inclusion criteria are articles that contain at least one or more social determinant of health categories or toolkit related topics. Filter criteria include academic journals, full text, peer reviewed articles, articles from the United States, articles published within the last 25 years, and articles written in the English language. Exclusion criteria are articles that measure patient perception in relation to social determinants of health. A literature review was conducted in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed database. The initial search was limited due to the inconsistent definitions and key words surrounding social determinants of health. The literature review was expanded to consist of articles published between 1996 – 2021. The initial screening before search limitations and screening for duplicates yielded 383 results. After applying the search limitations (full text, academic journals, peer reviewed, United States, and English language), the search yielded 276 articles. After removing 4 duplicates, 272 articles underwent further screening. A title and abstract review eliminated an additional two articles. A reference review of the articles included in the evidence table yielded an additional three articles. A total of 16 articles were included for analysis. Of the 16 articles included, the designs varied and included a systematic review, randomized controlled trial, quasi-experimental, prospective cohort, prospective intervention, pilot, observational, cross sectional, explanatory correlation, and secondary data analysis. A PRISMA diagram illustrates the evidence selection process (Figure 1). PROGRAM EVALUATION TOOLKIT 12 The John Hopkins Nursing Evidence-Based Practice evidence level and quality grade (Table 1) was used to grade the level and quality of evidence for this literature search result (Dang & Dearholt, 2017). The primary research included level I, II, and III evidence with a quality grade ranging from A-B (Appendix A). The search yielded six level I articles (Fowler & Reising, 2021; Hassann et al., 2015; Okafor et al., 2020, Omary et al., 2021; Garg et al., 2015, Sokol et al., 2019), three level II articles (Bechtel et al., 2021; Califf et all., 2021, To et al., 2014) and seven level III articles (Bittner et al., 2021; Buitron de la Vega et al., 2019; Baer et al., 2015; Sokol et al., 2021, Tsui et al., 2021, Kushel et al., 2006; Rust et al., 2020). There was one systematic review (Sokol et al., 2019) and it was classified as a level 1 with a quality A rating (Appendix B). Eight articles received a quality rating of A (Buitron de la Vega et al., 2019; Hassann et al., 2015; Okafor et al., 2020; Sokol et al., 2021; Garg et al., 2015; To et al., 2014; Sokol et al., 2019; Kushel et al., 2006). 7 articles received a quality rating of B (Baer et al., 2015; Bechtel et al., 2021; Bittner et al., 2021; Califf et al., 2021; Rust et al., 2020; Tsui et al., 2021; Fowler & Reising, 2021). One article received a quality rating of C (Omary et al., 2021). Critical Appraisal of the Evidence with Themes A thorough analysis of the literature identified the common themes and trends associated with screening for SDOH. The literature synthesis identified the following four themes: screening successfully identifies SDOH concerns, screening for SDOH encourages referrals to community resources, screening positive for SDOH is correlated with other negative health findings, and nursing toolkits and their importance to best practices. Screening for SDOH Identifies Concerns Food insecurity was among the most prevalent social domain identified in the literature and is associated with other social problems such as healthcare access, housing, income insecurity, and substance use (Bear et al, 2015; Bechtel et al, 2021; Buitron de la Vega et al., 2019; Hassann et al., 2015; Okafor et al, 2020; Sokol et al., 2021; Tsui et al., 2021; Kushel et PROGRAM EVALUATION TOOLKIT 13 al., 2006; To et al., 2014). Housing insecurity or hazards within the home was identified as a significant social domain need in over half of the articles included in the synthesis and is associated with postponing needed medical care, postponing medications, increased emergency department visits, and increased hospitalizations (Bear et al, 2015; Bechtel et al, 2021; Buitron de la Vega et al., 2019; Hassann et al., 2015; Sokol et al., 2021; Tsui et al., 2021; Kushel et al., 2006; To et al., 2014; Bittner et al., 2021). Financial insecurity or unemployment was identified as a major social domain problem in five different articles and results in problems affording medication (Buitron de la Vega et al., 2019; Hassann et al., 2015; Baer et al., 2015; Sokol et al., 2021; Bittern et al., 2021). In addition, an annual income of less than $75,000 was associated with an increased risk for having greater than two unmet social needs (Tsui et al., 2015; Garg et al., 2015). Screening for SDOH Encourages Referrals Implementation of a SDOH screening workflow was successful in identifying and providing relevant resource referrals (Buitron de la Vega et al., 2019; Hassann et al., 2015; Sokol et al., 2021; Garg et al., 2015; Bittner et al., 2021). In a randomized controlled trial of 336 mothers, they received at least one relevant resource referral, and after 12-months were enrolled in a new community resource (Garg et al., 2015). According to an observational study of 1,696 participants, 86% of participants received a relevant resource referral (Buitron de la Vega et al., 2019). Hassann et al (2015) revealed similar results with 83% of participants receiving a follow up notification for their identified need and 47% reported “completely” or “mostly” resolving their priority problem. Effects of Screening Positive for Unmet Needs Being negatively affected by SDOH increases the risk for comorbidities and other negative health practices. According to Califf et al (2021), PHQ-9 scores were higher among unemployed, unmarried, low education individuals, females, younger participants, and those with Hispanic ethnicity. Housing and food instability was independently associated with PROGRAM EVALUATION TOOLKIT 14 postponing necessary medical care, postponing medications, increased emergency department visits, and increased hospitalizations (Kushel et al., 2006). Finally, another study revealed that food insecurity in children is associated with less moderate to vigorous physical activity than food secure children and lack of adherence to physical activity in adults (Baer et al., 2015). Nursing Toolkits Supporting Best Practices Toolkits contribute to the nursing profession as guides for best practices. They are available to provide current and relevant information on a variety of topics such as electronic health records (EHR), fall prevention, post-acute care regulations, and prevention and management of obesity in adults (Fowler et al., 2021; Omary et al., 202; Rust et al., 2020; Worsowicz & Singh, 2019). There are multiple purposes for the use of toolkits such as increasing knowledge about best practices of nursing related topics, optimization of patient outcomes, and in enhancing patient care (Fowler et al., 2021; Omary et al., 202; Rust et al., 2020; Worsowicz & Singh, 2019). Fowler et al (2021) demonstrated improved patient outcomes following the use of a patient centered fall prevention toolkit. According to a pre and post intervention test, patients were more knowledgeable about fall risk factors and interventions, fall rates, and injury rates. Furthermore, there was an overall reduction in patient falls from 3.3% to 1.9%. Omary et al (2021) utilized a pre and post intervention test to determine nursing knowledge about use and management of EHR data into practice. One hundred percent of participants experienced a median of 17.6% increase in scores following use of the training content and assessments. In another study, a post-acute care (PAC) toolkit was utilized across an accountable care organization to assist physicians in choosing the most appropriate PAC setting when discharging a patient to ensure optimal patient outcomes (Worsowicz & Singh, 2019). A primary care clinic in Lexington Kentucky utilized steps from the Registered Nurses Association of Ontario toolkit to implement best practice guidelines for the prevention and management of obesity in adults (Rust et al., 2020). Following a 12-week period, providers were consistently PROGRAM EVALUATION TOOLKIT 15 assessing for comorbidities, setting appropriate goals, and successfully managing the weight of their obese patients. In addition, providers increased their documentation of readiness for change. Program Review Recommendation Statement The studies included in the literature synthesis examine a variety of populations and outcomes. The recommendation to screen for SDOH is a relatively new concept, but the literature focused primarily on pediatric populations. There is limited data available to address how SDOH affects adults. However, the literature is conclusive on the idea that screening for SDOH identifies unmet social needs, improves provider referrals, and improves overall health outcomes. In addition, the literature supports the use and development of nursing toolkits to influence evidence-based interventions in healthcare. Based on this literature review, the recommendation is that SDOH programs should be reviewed in accordance with the CDC’s PEF to guide the development of an implementation toolkit for SDOH screening in adult patients at primary care clinics. This recommendation answers the PICOT question: In adult clients seeking care at a primary care clinic (P), how does a SDOH toolkit based on the CDC framework (I) compared to no SDOH toolkit (C) affect identification of unmet health related social needs (O)? Program Analysis and Evaluation Plan A definitive toolkit for SDOH screening was not located within the literature. Therefore, as the PM reviewed practice/position statements, the development of an implementation SDOH toolkit took place to fill the gaps between current practice and best practices as supported by the literature. The Centers for Disease Control and Prevention (CDC) Program Evaluation framework (PEF) guided the implementation of the program change and development of the SDOH toolkit. The programs and toolkits that were selected for review are The Centers for Disease Control and Prevention, Healthy People 2030, and Health Leads (Health Leads screening PROGRAM EVALUATION TOOLKIT 16 toolkit). According to the AAFP, primary care is a natural point of integration amongst other forms of healthcare (public health, behavioral health, and community-based services). Healthy People 2030, CDC, and Health Leads were selected due to their dedication to improving overall health through data driven national objectives, community-level health initiatives, accelerating practice, and targeted advocacy. Engage Stakeholders The individuals who were affected by the program and toolkits should be used for the evaluation (CDC, 2018). The PM sought to understand the population of interest for each program and the intended audience for the toolkits. In doing so, the PM gained a better understanding of the stakeholders’ values and perspectives on important elements such as the program’s objectives, operations, and outcomes. Describe the Program To accurately depict the mission, goals, and objectives of the program being evaluated, the programs inputs, activities, outputs, outcomes, impacts, and moderators should be identified (CDC, 2017). Through identification of what the program does to affect change, the PM developed a logic model (Figure 2) which created a clear depiction of the link between program activities and the intended outcomes. Focusing the Evaluation Design The PM identified the purpose of the program and toolkit evaluation (gain insight, change practice, assess affects, and affect participants). The PM outlined the purpose of the program and toolkit evaluation as part of the project proposal. According to Harris et al. (2018) this stage of the framework guides the development of the project objectives utilizing the SMART goals format. Gather Credible Evidence Credible evidence provides for subsequent strong evaluation judgments and recommendations for change (CDC, 2017). In searching for such evidence, the PM investigated PROGRAM EVALUATION TOOLKIT 17 the partnerships, community-level health initiatives, and research conducted by the three selected programs to determine the success of each. Justify Conclusions An analysis and synthesis of the results of the evaluation should be applied to detect patterns by isolating important findings from each program and toolkit (CDC, 2017). In addition, the examination served to detect similarities among the programs to reach a larger understanding of its value. The PM interpreted the results to answer questions about the programs performance and practical significance, and then to make recommendations. These recommendations include whether to continue, expand, redesign, or terminate the program, and are based on evidence and stakeholder values from the CDC model. The recommendations were translated into the form of a more current and relevant toolkit for SDOH. Ensure Use and Share Lessons Learned A deliberate effort is required to ensure that the findings of the program and toolkit evaluation are distributed appropriately (CDC, 2017). As mentioned previously, the PM identified the design of the evaluation as part of the project proposal. This was important to highlight the intended purpose of the program analysis review. The PM utilized the findings of the program review to develop a toolkit for SDOH screening in primary care clinics. The PM developed a plan for dissemination to ensure the timely communication of lessons learned to the appropriate audiences. Program Evaluation Discussion and Recommendations Programmatic evaluation of existing social determinants of health programs was conducted using the CDC’s Program Evaluation framework to analyze the published content related to three SDOH programs: CDC, Healthy People 2030, and Health Leads. These programs were chosen for their emphasis on SDOH as well as applicability to the target population of adults in primary care. PROGRAM EVALUATION TOOLKIT 18 The evaluation utilized the six identified categories and evaluated the three programs thoroughly using the prescribed standards within each of the six categories. Across the three programs, the PM identified consistent findings related to stakeholder engagement, programmatic description, evaluation design, evidence credibility, programmatic evaluation standards to justify conclusions, and utilization and dissemination strategies. Each category was subdivided into standards ranging in number of four to nine depending on the evaluation step. Those standards were further categorized by group (accuracy, propriety, and utility). Each program was reviewed using the steps and standards tool and determined to meet expectations, exceed expectations, or not meet expectations based on the standard definitions and evidence review. This determination was then coded for descriptive statistical analysis with 0= not meet, 1= meet, 2= exceeds. The descriptive statistical mean value ≥1 indicates that the program consistently met the standards as related to the six program evaluation step criteria. The observations for Health People 2030 presented an average of 0.76, with CDC presented an average of 1.05, and the Health Leads program with an average of 1.11. See Table 2 for further details. Next, the programs were evaluated to understand their relevancy to the evidence synthesized in support of the development of an SDOH toolkit specifically for the adult primary care population. This evaluation consisted of applying the identified themes and supporting evidence and analyzing the three identified programs for currency of literature and relevancy to the population. This analysis is essential to understand the gap within the relevant literature and published programs to support the development of the population specific toolkit. This was accomplished by a thorough review of the published programs against the evidence with coding of present and current (PC), present and needs updating (PU), and missing current evidence (M). This evaluation determined that the CDC and Healthy People 2030 programs were published in two locations but the same program in terms of evidence relevancy and currency. PROGRAM EVALUATION TOOLKIT 19 Due to this identification the two programs are presented in the review as a single program. Health Leads, however, differed enough in content to be evaluated as a unique program (See Table 3). The evidence concurrency and relevancy to the literature review was statistically analyzed using Intellectus Statistical software (2021). A two-tailed Wilcoxon signed rank test was performed to understand if there was a significant difference between the analysis of the two identified programs, Healthy People 2030 (which includes the CDC duplicate program) and the Health Leads Network program. The two-tailed Wilcoxon signed rank test results were significant based on an alpha value of .05, V = 0.00, z = -2.53, p = .011. This indicates that the differences between Healthy_People_2030 and Health_Leads_Network are not likely due to random variation. The median of Healthy_People_2030 (Mdn = 1.00) was significantly lower than the median of Health_Leads_Network (Mdn = 2.00). See Figure 3 for a boxplot depiction of the ranked values of the two compared programs. The objectives of this project were to identify and evaluate three SDOH programs, objectively analyze the program content to develop practice recommendations, and develop a SDOH toolkit for a specialty population. The evaluation results indicate that the evaluated SDOH programs meet the requirements of a program as per the CDC Program Evaluation framework. Additionally, the evidence supports the use of these programs as established to support the development of a SDOH screening toolkit for the specialty population of adult primary care patients. The evaluation conclusion determined that the Health Leads Network program, according to the CDC Program Evaluation framework and the thematic analysis for currency and relevancy of evidence, is the more complete program for social determinants of health. Limitations of this review include the program evaluation was completed utilizing public, published content for programmatic implementation, but did not measure programs in use currently. Subject matter experts were consulted in the development of the SDOH for adult PROGRAM EVALUATION TOOLKIT 20 primary care toolkit, but the toolkit has not been placed into use at this time. See Appendix G for the Adult Primary Care SDOH Screening toolkit. Dissemination Plan Dissemination of the project was executed by the PM, who shared the project virtually with each organization discussed during the program evaluation. In addition, the PM disseminated the results via an in-person meeting the project outcomes with a primary clinic that serves uninsured and low-income populations. This project is archived within the University of Saint Augustine for Health Sciences Library Scholarship and Open Access Repository (SOAR) as a student capstone. A virtual poster presentation was submitted to disseminate the project to other DNP students and faculty at the University of St. Augustine for Health Sciences. Conclusion With growing interest in SDOH and its effects on health outcomes, a program evaluation review of the CDC, Health Leads, and Healthy People 2030 was a unique way to answer questions about the program’s performance and practical significance so that recommendations for change could be made. The objectives of this project were to identify and evaluate three SDOH programs, objectively analyze the program content to develop practice recommendations, and develop a SDOH toolkit for a specialty population. The evaluation results indicate that the CDC’s, Healthy People 2030, and Health Leads Network SDOH programs meet the requirements of a program as per the CDC Program Evaluation framework. Additionally, the evidence supports the use of these programs as established to support the development of a SDOH screening toolkit for the specialty population of adult primary care patients. A synthesis of the literature was effective in evaluating the meaning and relevance of the research findings which focused on screening for SDOH, identifying possibilities for addressing those unmet needs, and the role of toolkits in nursing. A complete and thorough program evaluation in accordance with the CDC’s program evaluation framework was useful for PROGRAM EVALUATION TOOLKIT 21 identifying gaps between existing knowledge surrounding SDOH screening for adult patients in primary care and best practices. Identification of said gaps led to the creation of a current SDOH toolkit for adult patients in primary care clinics complete with a purpose statement, audience recommendation, key definitions, implementation strategy, evaluation strategy and tool, stakeholder engagement and analysis tool, communication planning tools, position and policy statement, screening tool examples, and education for clinicians, patients, and their support

Communication deficits surrounding SDOH are a major cause for concern. Racial and cultural differences have resulted in distrust and poor communication, especially amongst black Americans and minorities (Butler & Sheriff, 2021). Poor communication reflects the shortcomings of the American health system and inhibits the goal of obtaining equitable care for all people.
The field of medicine places major emphasis on behavioral modification as the main strategy for disease and illness prevention (Andermann & CLEAR Collaboration, 2016). This approach has not proven to be the most effective strategy as individuals are not likely to be in control of health-related social factors that are contributing to their poor health outcomes (Andermann & CLEAR Collaboration, 2016). Broader interventions such as creating more supportive environments are necessary for reducing unhealthy behaviors and supporting healthy choices.
Widespread adoption of the electronic health record (EHR) has led to the creation of the Promoting Interoperability Programs (PIP) by the Centers for Medicare and Medicaid services (Chen et al., 2020). Stage three of the PIP involves the use of the EHR to demonstrate continuous quality improvement of care and elimination of healthcare inequality across all groups of people. The number of healthcare institutions that are exploring ways to capture SDOH data, referrals, and interventions to meet the needs of vulnerable populations is on the rise. Adoption of an SDOH toolkit is helpful for minimizing pitfalls and overcoming barriers to screening and treating for health-related social factors affecting patient outcomes.

Purpose of the Program Evaluation Project
The purpose of the program evaluation review project was to evaluate three professional organizations and their current SDOH screening programs according to best practices so that recommendations could be made for improvement. Secondly, by evaluating existing toolkits in practice for currency and relevance, a new toolkit was developed for the specialty population of adult patients in primary care. The newly developed toolkit more accurately represents the evidence related to reducing SDOH risks that contribute to poor adherence to health measures in at risk populations. The population of interest includes adults over age 18. The setting includes primary care clinics and any organization that supports the population of interest. The intervention includes an SDOH toolkit that was derived from evaluation of existing toolkits. In addition, the CDC's PEF served as the guide for the evaluation of the three professional organizations or government agencies so that recommendations for change could be made.

Project Objectives
The objectives of this project have been outlined using the SMART format (specific, measurable, attainable, realistic, and timed) and are as follows: 1. The project manager (PM) will identify three professional organizations or government agencies current social determinants of health screening program by the end of week 5 of the project proposal development period.
2. Using the CDC's program evaluation framework, the PM will make at least two recommendations through practice/position statements by the end of week four of the project proposal development period.
3. The PM will develop a social determinants of health toolkit to include an updated position statement, policy statement, screening tool examples, and current education materials for varied audiences by the end of week four of NUR7803.

Program Problem Statement
The PICOT that guided the development of this program evaluation review project is: In adult clients seeking care at a primary care clinic (P), how does a SDOH toolkit based on the CDC framework (I) compared to no SDOH toolkit (C) affect identification of unmet health related social needs (O)? The population of interest includes adults over age 18. The setting includes primary care clinics and any organization that supports the population of interest. Despite a growing interest in capturing data surrounding SDOH and the effects on health outcomes, there was a lack of an effective toolkit to conduct SDOH screening in primary care.

Utility of Program Review
Evidence-based toolkits improve healthcare and facilitate practice change to a variety of audiences (Barac et al., 2014). They often include useful materials such as implementation guidelines, participant training, and audit materials which are presented in a variety of formats (Yamada et al., 2015). A definitive toolkit for SDOH screening was not located within the literature.
Relevant stakeholders for the program evaluation, analysis, and the development of the SDOH screening toolkit include: health practitioners, patients, community and health organizations, policy makers, and members of the public. Reviewing SDOH programs through the lens of stakeholders is valuable because it provides insight into the values and perspectives on the program's objectives, operations, and outcomes (CDC, 2017).
Primary care is the setting that was most influenced by completing the program change because this setting most supports the population of interest. The American Academy of Family Physicians (AAFP) reports that screening for SDOH in primary care is critical because primary care is a natural point of integration amongst other forms of healthcare (public health, behavioral health, and community-based services) (AAFP, 2022). Fifty-one percent of adults in the United States made a visit to a primary care physician in 2019 (CDC, 2021). Based on this, screening for SDOH at primary care visits has the capacity to reach vulnerable patients to provide them with the support they need to improve their health outcomes. Thus, the evaluation, analysis and revision will improve current conditions by ensuring that practice/position statements are in alignment with what the literature suggest as best practice and using the CDC's PEF.

Analytical Framework
Program evaluation holds healthcare organizations accountable and committed to improving health outcomes. The CDC's PEF is a six-step process and is as follows: 1. Engage stakeholders 2. Describe the program 3. Focus the evaluation design 4. Gather credible evidence 5. Justify conclusions 6. Ensure use and share lessons learned.
Each step is interdependent but must be fulfilled to facilitate an accurate understanding of the program's context (CDC, 2017). Further discussion of each step provides a structured way to review a program and understand the standards for program effectiveness.

Engage Stakeholders
The evaluation cycle began by examining those individuals or organizations that will be affected by what was learned from the evaluation and what will be done with the knowledge.
The principal groups of stakeholders include those involved in program operations, those served or affected by the program, and the primary users of the evaluation. (CDC, 2017). During this step of the framework, the PM gained a better understanding of the stakeholders' values and perspectives on important elements such as the program's objectives, operations, and outcomes.

Describe the Program
Detailed program descriptions were necessary to convey the mission, goals, and objectives of the program being evaluated. A complete program description should include information about the programs need, expected effects, activities, resources, stage of development, context, and logic model (CDC, 2017). Program descriptions were useful during the program evaluation project to compare the program to similar programs. In addition, it helped to facilitate the connection between the program and its effects on healthcare.

Focusing the Evaluation Design
The standards for effective evaluation include utility, feasibility, propriety, and accuracy (CDC, 2017). These standards were met by planning the direction of the evaluation in advance.
The PM utilized this step of the framework to clarify the intent of the evaluation, identify how the results of the evaluation were to be used, and to develop practical methods for data collection, analysis, and interpretation.

Gather Credible Evidence
A successful and credible evaluation is one that collects information that produces an accurate depiction of the program in its entirety. Credible evidence provides for subsequent strong evaluation judgments and recommendations for change (CDC, 2017). During this stage of the framework evaluation, the PM identified indicators which served as a basis for measuring meaningful effects of the program (i.e.: ability to deliver services, client satisfaction, resource efficiency, etc.).

Justify Conclusions
Evaluation of conclusions can only be justified when they have been linked to the evidence gathered and when they have been compared to agreed upon benchmarks set by the stakeholders (CDC, 2017). This process required standards, analysis and synthesis, interpretation, judgement, and recommendations. The standards served as a basis for developing judgments about the program's performance success. Analysis and synthesis pinpointed patterns and findings about the evidence gathered. Interpretation was useful for understanding the significance of the information learned during the project evaluation.
Judgements were made about the significance of the program by comparing the findings to other pre-selected standards. Finally, the recommendation to continue, expand, redesign, or terminate a program was based on evidence and stakeholder values.

Ensure Use and Share Lessons Learned
The ensure use and share lessons learned phase of the framework involves the translation of evaluation findings into practice. The purpose of this step was to ensure that the evaluation achieved its primary purpose (CDC, 2017). Thus, the PM described the essential features of the program, defined the focus of the evaluation and any limitations, identified the strengths and weaknesses, and discussed any recommendations for action.

Evidence Search Strategy, Results, and Evaluation
The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed database were searched using the following Boolean operator, (social determinants of health) AND (social determinants of health screening tool). Key terms include social determinants of health, health equity, health inequality, health disparity, health risk assessment, and social determinants of health screening tool. An additional CINAHL search was performed with the following Boolean operator, nursing AND toolkit AND best practice. Inclusion criteria are articles that contain at least one or more social determinant of health categories or toolkit related topics.
Filter criteria include academic journals, full text, peer reviewed articles, articles from the United States, articles published within the last 25 years, and articles written in the English language.
Exclusion criteria are articles that measure patient perception in relation to social determinants of health.  (Table 1) was used to grade the level and quality of evidence for this literature search result (Dang & Dearholt, 2017). The primary research included level I, II, and III evidence with a quality grade ranging from A-B (Appendix A). The search yielded six level I articles (Fowler & Reising, 2021;Hassann et al., 2015;Okafor et al., 2020, Omary et al., 2021Garg et al., 2015, Sokol et al., 2019, three level II articles (Bechtel et al., 2021;Califf et all., 2021, To et al., 2014 and seven level III articles (Bittner et al., 2021;Buitron de la Vega et al., 2019;Baer et al., 2015;Sokol et al., 2021, Tsui et al., 2021, Kushel et al., 2006Rust et al., 2020). There was one systematic review (Sokol et al., 2019) and it was classified as a level 1 with a quality A rating (Appendix B).

Critical Appraisal of the Evidence with Themes
A thorough analysis of the literature identified the common themes and trends associated with screening for SDOH. The literature synthesis identified the following four themes: screening successfully identifies SDOH concerns, screening for SDOH encourages referrals to community resources, screening positive for SDOH is correlated with other negative health findings, and nursing toolkits and their importance to best practices.

Screening for SDOH Identifies Concerns
Food insecurity was among the most prevalent social domain identified in the literature and is associated with other social problems such as healthcare access, housing, income insecurity, and substance use (Bear et al, 2015;Bechtel et al, 2021;Buitron de la Vega et al., 2019;Hassann et al., 2015;Okafor et al, 2020;Sokol et al., 2021;Tsui et al., 2021;Kushel et al., 2006;To et al., 2014). Housing insecurity or hazards within the home was identified as a significant social domain need in over half of the articles included in the synthesis and is associated with postponing needed medical care, postponing medications, increased emergency department visits, and increased hospitalizations (Bear et al, 2015;Bechtel et al, 2021;Buitron de la Vega et al., 2019;Hassann et al., 2015;Sokol et al., 2021;Tsui et al., 2021;Kushel et al., 2006;To et al., 2014;Bittner et al., 2021). Financial insecurity or unemployment was identified as a major social domain problem in five different articles and results in problems affording medication (Buitron de la Vega et al., 2019;Hassann et al., 2015;Baer et al., 2015;Sokol et al., 2021;Bittern et al., 2021). In addition, an annual income of less than $75,000 was associated with an increased risk for having greater than two unmet social needs (Tsui et al., 2015;Garg et al., 2015).

Screening for SDOH Encourages Referrals
Implementation of a SDOH screening workflow was successful in identifying and providing relevant resource referrals (Buitron de la Vega et al., 2019;Hassann et al., 2015;Sokol et al., 2021;Garg et al., 2015;Bittner et al., 2021). In a randomized controlled trial of 336 mothers, they received at least one relevant resource referral, and after 12-months were enrolled in a new community resource (Garg et al., 2015). According to an observational study of 1,696 participants, 86% of participants received a relevant resource referral (Buitron de la Vega et al., 2019). Hassann et al (2015) revealed similar results with 83% of participants receiving a follow up notification for their identified need and 47% reported "completely" or "mostly" resolving their priority problem.

Effects of Screening Positive for Unmet Needs
Being negatively affected by SDOH increases the risk for comorbidities and other negative health practices. According to Califf et al (2021), PHQ-9 scores were higher among unemployed, unmarried, low education individuals, females, younger participants, and those with Hispanic ethnicity. Housing and food instability was independently associated with postponing necessary medical care, postponing medications, increased emergency department visits, and increased hospitalizations (Kushel et al., 2006). Finally, another study revealed that food insecurity in children is associated with less moderate to vigorous physical activity than food secure children and lack of adherence to physical activity in adults (Baer et al., 2015).

Nursing Toolkits Supporting Best Practices
Toolkits contribute to the nursing profession as guides for best practices. They are available to provide current and relevant information on a variety of topics such as electronic health records (EHR), fall prevention, post-acute care regulations, and prevention and management of obesity in adults (Fowler et al., 2021;Omary et al., 202;Rust et al., 2020;Worsowicz & Singh, 2019). There are multiple purposes for the use of toolkits such as increasing knowledge about best practices of nursing related topics, optimization of patient outcomes, and in enhancing patient care (Fowler et al., 2021;Omary et al., 202;Rust et al., 2020;Worsowicz & Singh, 2019). Fowler et al (2021) demonstrated improved patient outcomes following the use of a patient centered fall prevention toolkit. According to a pre and post intervention test, patients were more knowledgeable about fall risk factors and interventions, fall rates, and injury rates. Furthermore, there was an overall reduction in patient falls from 3.3% to 1.9%. Omary et al (2021) utilized a pre and post intervention test to determine nursing knowledge about use and management of EHR data into practice. One hundred percent of participants experienced a median of 17.6% increase in scores following use of the training content and assessments.
In another study, a post-acute care (PAC) toolkit was utilized across an accountable care organization to assist physicians in choosing the most appropriate PAC setting when discharging a patient to ensure optimal patient outcomes (Worsowicz & Singh, 2019). A primary care clinic in Lexington Kentucky utilized steps from the Registered Nurses Association of Ontario toolkit to implement best practice guidelines for the prevention and management of obesity in adults (Rust et al., 2020). Following a 12-week period, providers were consistently assessing for comorbidities, setting appropriate goals, and successfully managing the weight of their obese patients. In addition, providers increased their documentation of readiness for change.

Program Review Recommendation Statement
The studies included in the literature synthesis examine a variety of populations and outcomes. The recommendation to screen for SDOH is a relatively new concept, but the literature focused primarily on pediatric populations. There is limited data available to address how SDOH affects adults. However, the literature is conclusive on the idea that screening for SDOH identifies unmet social needs, improves provider referrals, and improves overall health outcomes. In addition, the literature supports the use and development of nursing toolkits to influence evidence-based interventions in healthcare.
Based on this literature review, the recommendation is that SDOH programs should be reviewed in accordance with the CDC's PEF to guide the development of an implementation toolkit for SDOH screening in adult patients at primary care clinics. This recommendation answers the PICOT question: In adult clients seeking care at a primary care clinic (P), how does a SDOH toolkit based on the CDC framework (I) compared to no SDOH toolkit (C) affect identification of unmet health related social needs (O)?

Program Analysis and Evaluation Plan
A definitive toolkit for SDOH screening was not located within the literature. Therefore, as the PM reviewed practice/position statements, the development of an implementation SDOH toolkit took place to fill the gaps between current practice and best practices as supported by The programs and toolkits that were selected for review are The Centers for Disease Control and Prevention, Healthy People 2030, and Health Leads (Health Leads screening toolkit). According to the AAFP, primary care is a natural point of integration amongst other forms of healthcare (public health, behavioral health, and community-based services). Healthy People 2030, CDC, and Health Leads were selected due to their dedication to improving overall health through data driven national objectives, community-level health initiatives, accelerating practice, and targeted advocacy.

Engage Stakeholders
The individuals who were affected by the program and toolkits should be used for the evaluation (CDC, 2018). The PM sought to understand the population of interest for each program and the intended audience for the toolkits. In doing so, the PM gained a better understanding of the stakeholders' values and perspectives on important elements such as the program's objectives, operations, and outcomes.

Describe the Program
To accurately depict the mission, goals, and objectives of the program being evaluated, the programs inputs, activities, outputs, outcomes, impacts, and moderators should be identified (CDC, 2017). Through identification of what the program does to affect change, the PM developed a logic model (Figure 2) which created a clear depiction of the link between program activities and the intended outcomes.

Focusing the Evaluation Design
The PM identified the purpose of the program and toolkit evaluation (gain insight, change practice, assess affects, and affect participants). The PM outlined the purpose of the program and toolkit evaluation as part of the project proposal. According to Harris et al. (2018) this stage of the framework guides the development of the project objectives utilizing the SMART goals format.

Gather Credible Evidence
Credible evidence provides for subsequent strong evaluation judgments and recommendations for change (CDC, 2017). In searching for such evidence, the PM investigated the partnerships, community-level health initiatives, and research conducted by the three selected programs to determine the success of each.

Justify Conclusions
An analysis and synthesis of the results of the evaluation should be applied to detect patterns by isolating important findings from each program and toolkit (CDC, 2017). In addition, the examination served to detect similarities among the programs to reach a larger understanding of its value. The PM interpreted the results to answer questions about the programs performance and practical significance, and then to make recommendations. These recommendations include whether to continue, expand, redesign, or terminate the program, and are based on evidence and stakeholder values from the CDC model. The recommendations were translated into the form of a more current and relevant toolkit for SDOH.

Ensure Use and Share Lessons Learned
A deliberate effort is required to ensure that the findings of the program and toolkit evaluation are distributed appropriately (CDC, 2017). As mentioned previously, the PM identified the design of the evaluation as part of the project proposal. This was important to highlight the intended purpose of the program analysis review. The PM utilized the findings of the program review to develop a toolkit for SDOH screening in primary care clinics. The PM developed a plan for dissemination to ensure the timely communication of lessons learned to the appropriate audiences.

Program Evaluation Discussion and Recommendations
Programmatic evaluation of existing social determinants of health programs was conducted using the CDC's Program Evaluation framework to analyze the published content related to three SDOH programs: CDC, Healthy People 2030, and Health Leads. These programs were chosen for their emphasis on SDOH as well as applicability to the target population of adults in primary care.
The evaluation utilized the six identified categories and evaluated the three programs thoroughly using the prescribed standards within each of the six categories. Across the three programs, the PM identified consistent findings related to stakeholder engagement, programmatic description, evaluation design, evidence credibility, programmatic evaluation standards to justify conclusions, and utilization and dissemination strategies. Each category was subdivided into standards ranging in number of four to nine depending on the evaluation step.
Those standards were further categorized by group (accuracy, propriety, and utility).
Each program was reviewed using the steps and standards tool and determined to meet expectations, exceed expectations, or not meet expectations based on the standard definitions and evidence review. This determination was then coded for descriptive statistical analysis with 0= not meet, 1= meet, 2= exceeds. The descriptive statistical mean value ≥1 indicates that the program consistently met the standards as related to the six program evaluation step criteria.
The observations for Health People 2030 presented an average of 0.76, with CDC presented an average of 1.05, and the Health Leads program with an average of 1.11. See Table 2  This evaluation determined that the CDC and Healthy People 2030 programs were published in two locations but the same program in terms of evidence relevancy and currency.
Due to this identification the two programs are presented in the review as a single program.
Health Leads, however, differed enough in content to be evaluated as a unique program (See Table 3).
The evidence concurrency and relevancy to the literature review was statistically analyzed using Intellectus Statistical software (2021) Limitations of this review include the program evaluation was completed utilizing public, published content for programmatic implementation, but did not measure programs in use currently. Subject matter experts were consulted in the development of the SDOH for adult primary care toolkit, but the toolkit has not been placed into use at this time. See Appendix G for the Adult Primary Care SDOH Screening toolkit.

Dissemination Plan
Dissemination of the project was executed by the PM, who shared the project virtually with each organization discussed during the program evaluation. In addition, the PM disseminated the results via an in-person meeting the project outcomes with a primary clinic that serves uninsured and low-income populations. This project is archived within the University of Saint Augustine for Health Sciences Library Scholarship and Open Access Repository (SOAR) as a student capstone. A virtual poster presentation was submitted to disseminate the project to other DNP students and faculty at the University of St. Augustine for Health Sciences.

Conclusion
With growing interest in SDOH and its effects on health outcomes, a program evaluation review of the CDC, Health Leads, and Healthy People 2030 was a unique way to answer questions about the program's performance and practical significance so that recommendations for change could be made. The objectives of this project were to identify and evaluate three SDOH programs, objectively analyze the program content to develop practice recommendations, and develop a SDOH toolkit for a specialty population. The evaluation results indicate that the CDC's, Healthy People 2030, and Health Leads Network SDOH programs meet the requirements of a program as per the CDC Program Evaluation framework.
Additionally, the evidence supports the use of these programs as established to support the development of a SDOH screening toolkit for the specialty population of adult primary care patients.         Knowledge-To-Action conceptual framework The framework articulates the complex process where new healthcare information is created (the "knowledge cycle") and then applied at the bedside (the "action cycle") Audits of records were conducted during the first and third month following the educational intervention to evaluate whether the CPG was being implemented appropriately using a tool that evaluated each step of the algorithm to determine if care was congruent with the CPG recommendations.
Providers were setting goals and discussing strategies to promote a healthy weight in greater than 91% of reviewed episodes of care Readiness for weight management was being documented in less than 40% of patients with a BMI in the obese range (consistent with findings in the literature demonstrating that visit time limitations make it difficult for providers to address weight as a stand-alone health concern in patients with both obesity and comorbidities) Patients classified as overweight discussed weight management with providers almost 90% of the time.

III. EVALUATION STRATEGY AND TOOLS:
A methodology is necessary to establish whether the implementation of social determinant of health screening was functional. This is done through use of an audit tool such as the one below. The tool below is generalized and can be adapted to meet the needs and goals of the clinic.

IV. STAKEHOLDER ENGAGEMENT AND ANALYSIS TOOL
Stakeholders are the individuals, group, and organizations that are most affected by the clinic. Examples of primary stakeholders include upper management, physicians, nurse practitioners, triage, patients, and their family and support people. These individuals can help facilitate change within the clinic, but they can also be responsible for resistance which could negatively impact the results of the intended change. To maintain successful relationships with the stakeholders of the project change, there must be a way to monitor stakeholder engagement. The stakeholder analysis template below is one way to identify the stakeholders, their relationship to the project, and their level of commitment.

V. COMMUNICATION PLANNING TOOLS:
Effective communication is key to the success of any project change. Communication ensures that all participants are on the same page, and it also helps to keep everyone

VI. POSITION STATEMENT:
Screening for social determinants of health is a vital component of the patient's complete health history and should be reviewed and updated at least annually to ensure optimal health outcomes.

VII. POLICY STATEMENT:
Primary care providers should ensure that an up-to-date screening for social determinants of health is on file annually. The PCP should review the results of the screen, determine if help for the unmet social need is requested, provide an adequate resource, or refer per the clinics policy and procedures, and follow up accordingly to ensure the need has been met.

VIII. SCREENING TOOL EXAMPLES:
There are numerous screening tools that are prominent in the literature. The tools vary according to the populations they serve, length of the screening tool, and subject matter.
Organizations and government agencies such as the Health Leads Network, The