Resident education and referral tools to address social drivers of health in primary care

Despite ACGME requirements to address structural and social drivers of health (SDOH), residents must balance competing learning objectives and lack of time and support to become familiar with local resources and make referrals. We designed a quality improvement project that aimed at increasing patient access to appropriate community-based referrals to address SDOH. We implemented a continuous quality improvement process with iterative Plan-Do-Study-Act cycles. In Cycle 1 following a needs assessment of patients and providers, we developed a curriculum on social needs (delivered January-March 2021) and evaluated resident familiarity and comfort with resources through a pre, immediate post, and one-month post-survey. In Cycle 2 to minimize reliance on provider memory, we created two referral mechanisms which became available January 2022: electronic health record shortcuts (dotphrases) and a patient-facing website. For sustainability, in Cycle 3, we adapted the curriculum to focus on the importance of addressing social needs and introduce incoming residents to referral mechanisms. To assess uptake, we monitored dotphrase usage and website traffic quarterly from January 2022 to December 2023. Over a two-year period, dotphrases were used in 1,255 completed office visits (5.48%), and website traffic appeared consistent throughout, suggesting sustained clinical adoption of these referral tools. Earlier survey data collected following the initial educational curriculum showed increases in self-reported resident comfort (2.8 to 3.6, p = 0.01) and familiarity (2.3 to 3.7, p < 0.01) with SDOH resources; however, these gains were not maintained at one-month follow-up (comfort: 3.5, p = 0.08; familiarity: 3.3, p = 0.02), suggesting that knowledge-based gains from education alone may not be durable. In a busy clinic without social work, our curriculum now focuses on strengthening resident commitment to addressing SDOH. Our referral mechanisms simplified resource distribution, reduced clinician burden, and allowed patients to access resources without disclosing needs. Dotphrase usage was sustained over time in a way resident knowledge was not.