Date Approved


Graduate Degree Type


Degree Name

Nursing (D.N.P.)

Degree Program

College of Nursing

First Advisor

Dr. Marie VanderKooi

Second Advisor

Dr. Joy Washburn

Academic Year



Background and Objectives: There is a need to screen, assess, and potentially make referrals for social determinants of health (SDOH) to help coordinate healthcare services across the care continuum and identify factors impacting health.

Problem: The majority of primary care offices do not routinely screen patients for social needs, despite the influence they can have on an individual’s health.

Methods: This quality improvement project was implemented using the Plan-Do-Study-Act (PDSA) framework at a small, midwestern rural primary care clinic in the United States. Participants included office staff and 31 adult patients who presented to the clinic for their wellness exam. A standardized evidence-based tool was implemented to screen for food insecurities among patients, and then information about a variety of community resources were offered to aid the individual with their unmet social need. The quality improvement measures included: total number of patients screened, community resource information provided to patients, resources utilized by patients, and staff understanding of SDOH components through semi-structured interviews.

Results: One patient (N=1) screened positive for a food insecurity out of 31 patients. This patient utilized one of three community resources provided. An additional two patients denied having food insecurity, but accepted the resources. Office medical assistants showed an increased understanding of screening for food insecurities and SDOH.

Conclusion: A screening tool can be effectively implemented through following the PDSA process to identify food insecurities among patients within a primary care clinic.

Keywords: Quality improvement, primary care, social determinants of health, food insecurities, referrals, community resources.