Social determinants of health screening and mitigation strategies: a cystic fibrosis quality improvement process

Introduction: Lower socioeconomic status is associated with significantly poorer outcomes in weight, lung function, and pulmonary exacerbation rates in People with CF (PwCF). Global aim: We aim to reduce health disparities and inequities faced by PwCF by screening for and addressing unmet social needs. Specific aims: We aimed to increase routine Social Determinants of Health (SDoH) screening of eligible PwCF from 0% to 95% and follow-up within two weeks for those PwCF who screened positive and requested assistance from 0% to 95% by December 31, 2021. Methods: The Model for Improvement methodology was employed. A process map and a simplified failure mode effects analysis chart were created for the screening and SDoH follow-up process. Those who screened positive for SDoH and requested assistance, a follow-up contact was made to offer intervention. Intervention: Adult PwCF who had at least one UVA Clinic encounter in 2021 were screened for SDoH. The SDoH screening tool included eight domains: housing, food, transportation, utilities, health-care access, medication access, income/employment and education. Follow-up was completed with all PwCF who screened positive for SDoH. Results: A total of 132 of 142, (93.0%) PwCF eligible for screening completed the SDoH screening. Of the PwCF who completed screening, 56 (42.4%) screened positive for SDoH. A follow-up rate of 100% was achieved in June 2021 and maintained through December 2021. Conclusion: Implementing screening for SDOH and follow-up to mitigate social difficulties in adult PwCF at UVA was successful and could be reproduced at other CF care center.