Social Determinants of Health Education in a Rural Primary Care Clinic

Background: Social Determinants of Health (SDH) are non-medical factors that significantly influence health outcomes and lead to health disparities. These determinants, such as inadequate housing, lack of transportation, food insecurity, and unsafe environments, limit individuals’ ability to access healthcare and manage chronic conditions effectively (Bechtel et al., 2022; Martinez-Alfonso et al., 2025). The Health-Related Social Needs (HRSN) screening tool, recommended by CMS, evaluates five domains: housing instability, food insecurity, transportation, utility needs, and safety (Centers for Medicare & Medicaid Services [CMS], n.d.-a). This quality improvement project was conducted at a rural primary care clinic in northern Arizona, serving a population of 66,021, with a median household income about half the state’s average and a poverty rate more than double the state average at 29.8% (United States Census Bureau, 2020). Before this project, the clinic did not routinely assess patients for adverse social determinants, presenting an opportunity to enhance patient care.Purpose: The project aimed to educate staff on the use of the HRSN screening tool and assess baseline knowledge, confidence, and awareness of local resources related to SDH. Methods: Staff completed pre- and post-intervention surveys, using a Likert scale to rate their understanding of SDH, knowledge of local resources, and confidence in conducting SDH screening in the clinic. Results: Survey data indicated that SDH screening is feasible and appropriate for this setting. Staff recognized the importance of SDH on health outcomes and expressed growing confidence in implementing the screening. However, they requested more support and education on available community resources and how each clinic role can participate in connecting patients to these resources. Conclusions: SDH screening is suitable for implementation at the clinic. Ongoing education on community resources and broader staff involvement are needed to optimize screening and patient support. Future efforts should include multidisciplinary collaboration and continuous evaluation of resource awareness.