Fig. 1

Workflow for Sutter Health SDOH Pilot. (1) Upon checking in, the patient receives the paper questionnaire from the PSR. (2) The patient completes the questionnaire in between checking in and being roomed by the MA. (3) The MA collects the questionnaire from the patient prior to the beginning of the MD visit. (4) The MA enters the paper questionnaire results into Epic. (5) The MA reviews which social needs have been identified based on the patient’s responses and discusses the identified social needs with the MD, which guides the MD in determining which potential actions to discuss with the patient during the exam. (6) The patient and the MD discuss social needs and actions and agree upon the next steps that will take place with the MD and/or a case manager/social worker. Beyond step 6, the secondary pilot workflow includes describes these next steps which would only occur for pilot patient participants with identified social needs who desire the actions. For six domains, the MD would work directly with the patient to support their ongoing needs. For two domains, the MD would refer the patient to a Sutter Health CM/SW. The CM/SW would in turn connect with the patient and identify relevant outside service providers to support the patient’s needs. (7) Once the paper questionnaire results have been entered and used, the MA returns the completed questionnaire to the PSR. (8) The PSR scans a copy of the paper questionnaire to Epic for data quality checks (and during the pilot specifically, emails that copy to the pilot evaluators). (9) The PSR securely disposes of the paper questionnaire