Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Dianne Conrad, DNP, FNAP, FNP-BC

Second Advisor

Marie Vanderkooi, MSN, DNP

Third Advisor

Rachel Cardosa, DNP, RN

Fourth Advisor

Simin Beg, MD, MBA


Background and Objectives: Addressing social determinants of health (SDOH) in the medical community has recently started; however, there is yet to be a standardized format for addressing the social needs of patients. Consequently, a protocol was developed to address SDOH to increase screening rates, social work referrals, and capture depression reimbursement.

Methods: The quality improvement project was implemented using the Plan-Do-Study-Act framework at an urban Community-Based Palliative Care organization in the Midwestern United States. Participants included office staff and 140 patients (two separate sets of 70 randomly selected patients pre/post-implementation). A protocol was developed for screening 11 SDOH using an already existing tool (SDOH wheel) in the electronic health record (EHR). Screening indicated if patients were at low, moderate, or high risk for each SDOH component and the need to refer to social workers. Reimbursement for depression, a component of SDOH, was captured. The QI project measures included: total number of patients and components screened, social work contacts made, and depression screening reimbursement for three months pre/post-implementation.

Results: There was a statistically significant increase in the number of patients (n= 70, p < 0.0001, Fisher’s exact test), number of components screened (χ2: 49.6827, p <0.0001) and social work contacts (χ2: 5.1225, p < 0.0236) three-month post implementation. Total reimbursement for depression increased from $0 to $90 post-implementation.

Conclusion: The protocol for screening and documenting SDOH improved screening rates, social work referrals, and depression reimbursement for vulnerable populations in a Community-Based Palliative Care setting.

Available for download on Monday, May 06, 2024

Included in

Nursing Commons