Implementing a Social Needs Screening and Referral Program Among Veterans: Assessing Circumstances & Offering Resources for Needs (ACORN)

With increasing recognition of the impact of social and behavioral determinants on health outcomes, policy makers, payers, and professional organizations have called for health systems to improve their means of identifying and addressing health-related social needs (HRSNs) including food insecurity, housing instability, interpersonal violence, and lack of transportation.^1‐5 While screening for HRSNs is increasingly being implemented in healthcare settings, widespread implementation remains relatively low.⁶

Veterans receiving care within the Department of Veterans Affairs (VA) healthcare system are routinely screened for housing instability⁷, food insecurity⁸, and intimate partner violence.⁹ However, VA does not systematically screen for HRSNs more broadly. To address this gap, our interprofessional team developed a Veteran-tailored HRSN screening and referral quality improvement initiative, “Assessing Circumstances and Offering Resources for Needs” (ACORN). ACORN aims to equip clinical teams with up-to-date information to better understand and address the social and economic factors impacting patients’ health.

We evaluated ACORN at 2 VA outpatient primary care clinics. Specifically, we assessed (1) prevalence of identified HRSNs; (2) Veteran-reported acceptability of ACORN; and (3) use of geographically tailored resource guides.

In this Veteran-tailored HRSN screening and referral initiative, half of Veterans screened reported  1 or more HRSNs (42% in a suburban clinic; 68% in an urban clinic). Across both clinics, social isolation was the greatest unmet need, which was endorsed by nearly one-third of Veterans. One in 5 participants reported at least some form of material hardship. Regardless of whether or not they reported HRSNs, Veterans felt screening was acceptable and important, and that VA should continue screening.

To our knowledge, this is the first study of a systematic HRSN screening and referral program among Veterans. The high rate of social isolation among those screened is particularly notable, as our data were collected primarily before the COVID-19 pandemic and reported social isolation and loneliness—which are associated with numerous adverse health outcomes among Veterans including increased risk for re-hospitalization and decreased well-being^26,27—have worsened globally since that time.^28,29 We also found substantially higher rates of food insecurity and housing instability than has been previously reported within VA despite our using the same screening questions.^7,30,31 These findings may be due, in part, to the fact that ACORN was Veteran self-administered whereas VA clinical reminders are staff-administered. Prior research has found patients prefer self-administered over staff-administered screening for HRSNs^32‐34, and that disclosure rates for food or financial insecurity and other sensitive topics such as exposure to violence and substance use are higher with self-administered screening.^32,34‐36 Rates of other HRSNs reported in ACORN were also higher than those found in other studies using VA EHR data such as ICD-10 codes³⁷, which are known to be underutilized.^38‐40

The ability to systematically screen for HRSNs and allow patients to self-administer screening is a strength of ACORN and has the potential to markedly improve the quality and accuracy of VA data. Self-administered, tablet-based screening allows for increased privacy, greater efficiency, and real-time review of responses by clinical staff.^36,41 Previous research has further demonstrated that Veterans prefer tablet-based to paper-based screening, and that completion rates were significantly higher with tablet-based screening.¹¹ Future work is needed to explore potential differences in Veteran and staff acceptability, perceived feasibility, and HRSN disclosure rates between Veteran self-administered and staff-administered screening.

Our findings of high rates of acceptability of screening for HRSNs are consistent with prior work in non-VA healthcare settings.^42‐44 Notably, in our study and others, even patients who did not endorse unmet needs spoke to the importance of universal screening. Future work is needed to establish an evidence base for optimal screening frequency, and how frequency may differ for routine screening versus follow-up assessments once needs are identified or in high-risk populations where needs may be more prevalent.

Despite widespread support for healthcare-based social needs screening, previous work has found many patients screening positive for HRSNs decline assistance or do not follow-up with offered resources.^{42,43,45‐54} Among the subset of Veterans we interviewed, none who screened positive for HRSNs had used resource guides at 2-week follow-up, although several noted planning to use them in the future. Consistent with prior work, reasons Veterans did not use resources included not feeling they had a current need, competing priorities, and not remembering receiving the guides.^{42,45,46,49,52} Since this pilot, ACORN has expanded to over 15 VA facilities nationally across different clinical settings, and in collaboration with our operational partners, we have worked with local teams to support the development of site-specific workflows to ensure appropriate follow-up and referrals are provided.⁵⁵ We have also established a Community of Practice to support and sustain implementation at both new and existing sites. Recognizing that optimal practices may vary based on patient preferences and needs, local resources, and staffing, there is likely not a one-size-fits-all approach to identifying and addressing HRSNs. Additional research is needed to better understand which patients may benefit from “low-touch” interventions such as tailored resource guides, and which patients need “higher-touch” interventions such as navigation or case management.

Our findings should be interpreted within the context of several limitations. First, this initiative took place in 2 VA primary care clinics in New England, which may limit generalizability. Second, COVID-19 lockdowns led to a drop in screenings in the suburban clinic due to decreases in clinic volume and staffing, and screening in the urban clinic halted completely in March 2020. Future work should examine whether enabling Veterans to securely complete an electronic screener remotely, such as through a patient portal, may help scale HRSN screening efforts and response. However, it is important to note that digital health inequities (i.e., lack of access to an internet-connected device and/or low digital health literacy) may prevent some Veterans from accessing these tools. Third, numbers and demographics of Veterans declining screening were not reliably collected by clinic staff and findings may have been susceptible to selection bias. Demographics of those screened, however, were generally similar to the broader patient population in each of the clinics with the exception that our sample was overall younger and more likely to be single. Fourth, Veteran-reported acceptability of ACORN was based on interviews with a subset of participants and may not be representative of all patients. We did, however, purposively sample Veterans who did and did not screen positive for HRSNs, and reached saturation within each stratum. Lastly, reported acceptability and importance of screening may have been subject to social desirability bias, although we tried to mitigate this bias by ensuring all respondents knew their responses would be anonymized and asking opened-ended questions in a non-judgmental way. Despite these limitations, our findings have important implications for our understanding of identifying and addressing HRSNs in healthcare settings.

A self-administered electronic HRSN screening and referral program identified that Veterans have substantial HRSNs and want VA to screen for and address these needs. Although health systems cannot independently address upstream determinants of health, they can serve as leaders and advocates in the identification and management of patients’ HRSNs. Screening for HRSNs is a critical step towards connecting patients with needed services, identifying gaps in the current service delivery system, and informing future resource allocation.