Date of Conferral

2-18-2026

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Corinne Romano

Abstract

Unmet social determinants of health (SDOH) contribute significantly to poor health outcomes, increased healthcare utilization, and persistent inequities in access to care. In a primary care organization, the inconsistent identification and management of patients’ social needs resulted in variable documentation, limited referrals to social work services, and avoidable emergency department (ED) utilization. The purpose of this Doctor of Nursing Practice (DNP) project was to develop an executive leadership systems implementation proposal to standardize the identification and referral of at-risk patients through the integration of a validated social needs screening tool into the electronic health record (EHR). The guiding practice-focused question examined whether implementing a standardized screening tool, compared with non-standardized practices, would increase timely identification and referral of adult primary care patients to social work services and reduce avoidable ED utilization. The proposed intervention includes embedding the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) or Accountable Health Communities Health-Related Social Needs (AHC-HRSN) screening tool within the EHR, supported by automated referral processes, standardized workflows, staff training, and performance dashboards. Key stakeholders include providers, nurses, medical assistants, social workers, administrators, information technologists, and community partners. Outcome measures consist of screening completion rates, referral frequency and completion, ED utilization, patient experience, staff satisfaction, and equity indicators. Evaluation will use formative and summative methods, with data extracted from EHR reports and patient surveys and analyzed through descriptive pre- and post-comparisons. Implementation goals include achieving greater than 90% screening completion, increasing social work referrals by at least 50%, and reducing ED utilization among high-risk patients by 15% or more. A phased approach involving tool integration, staff training, pilot testing, workflow refinement, and system-wide scaling supports sustainability. The projected project cost is approximately $4,000, with an estimated return on investment of 82% through reductions in avoidable ED visits. This project strengthens nursing leadership in population health, advances evidence-based practice, and operationalizes diversity, equity, and inclusion by ensuring fair, needs-based access to supportive resources. Standardized SDOH screening and referral processes are expected to enhance care coordination, improve patient outcomes, support value-based performance, and contribute to sustainable positive social change within the healthcare system.

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