Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Marie VanderKooi

Second Advisor

Joy Turner Washburn

Third Advisor

Kristin Batts


Background: Social Determinants of Health (SDOH), such as food, transportation, housing, and financial status, plays a significant role in a diabetic patient’s health care outcome. However, primary healthcare centers lack a systematic method of identifying patients with unmet social needs in order to provide appropriate referrals to community resources.

Objective: This project seeks to improve the screening methods of SDOH in a midwestern federally qualified primary healthcare center by incorporating an evidence based SDOH screening tool. This SDOH screening tool is tailored towards diabetic patients.

Method: Kotter’s Eight Step Change model guided the implementation process of this quality improvement project.

Results: There was no significant increase in the referral rates made to community services in relation to social needs, such as transportation, food, housing, and financial issues. This finding is related to (a) stakeholder’s limited time and resources to distribute the SDOH screening tool, (b) frequent modifications made to workflow, (c) patients having previous established community resources, and (d) patient-provider schedule fluctuations.

Conclusions: Although no significant increase in the referral rates to community resources were seen, this project assisted the site in assessing the limitations and strengths of implementing a SDOH screening tool. Some of the recommendations presented after the project evaluation are incorporating an annual SDOH screening tool for all patients and track patient referrals through the Electronic Health Record (EHR).