This study examines social risk factor screening and referral processes in cancer survivorship care, focusing on workflows, barriers, and opportunities across 3 oncology settings in Washington, DC. Social risk factors, such as food insecurity, transportation challenges, and financial strain, are recognized as negatively impacting health outcomes. Despite their importance, none of the participating institutions had systematic processes for identifying cancer survivors or screening for social risk factors.
Key Findings
- Existing Practices
- None of the clinics had standardized survivorship programs or workflows for addressing social risk factors
- Social risk factor screening was primarily informal, with referrals depending on individual relationships or outdated lists of community resources
- Barriers
- Staffing Limitations: Clinics lacked dedicated roles for social care, and existing staff often had competing responsibilities
- EHR Challenges: Tracking survivorship status, social risk factors, and referral outcomes was inconsistent due to limitations in electronic health records (EHR) functionality
- Environmental Constraints: Limited availability and inconsistent eligibility criteria of community resources hindered referrals
- COVID-19 Impacts: The pandemic exacerbated staffing shortages and weakened team-based care structures
- Opportunities
- Improved EHR Systems: Enhanced tools for documenting social risk factors and tracking referrals could streamline workflows
- Dedicated Staff Roles: Assigning personnel to handle social risk screening and referrals could reduce the burden on existing staff
- Strengthened Community Partnerships: Maintaining up-to-date referral directories and improving communication with local organizations could facilitate resource access for patients
Recommendations
- Develop systematic workflows for identifying cancer survivors and screening for social risk factors
- Invest in EHR optimization to track referrals and outcomes
- Allocate resources for dedicated staff to manage social care activities
- Build stronger relationships with community-based organizations to ensure timely and effective referrals
Conclusion
The study identifies gaps in survivorship care related to social risk factor screening and referrals. Addressing these gaps requires tailored approaches that account for differences in institutional resources, staffing, and patient needs. Improved processes could enhance survivorship care and reduce disparities in health outcomes.
Source
Astorino JA, Pratt-Chapman ML, Schubel L, et al. Contextual factors relevant to implementing social risk factor screening and referrals in cancer survivorship: a qualitative study. Prev Chronic Dis. 2024;21:230352. doi:10.5888/pcd21.230352
