Evidence mapPaperPMID 41473341Full record

ArticleHealth services insights2025

From Mandate to Meaning: A Health Equity Implementation Framework and Knowledge-to-Action-Informed Qualitative Study of Health-Related Social Needs Implementation.

Rachel P Zimmer, Camelia Singletary, Aylin Aguilar, Emily R Haines, Allison Chandler, Amresh Hanchate, Kristie Foley, Ashley Strahley, Marc Caruana, Sarah A Birken

Abstract read
In one paragraph

Article in Health services insights, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

10 authors.

Rachel P ZimmerDepartment of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.ORCID https://orcid.org/0000-0003-1037-069X
Camelia SingletaryDepartment of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Aylin AguilarDepartment of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Emily R HainesDepartment of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Allison ChandlerDepartment of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Amresh HanchateDepartment of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Kristie FoleyDepartment of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Ashley StrahleyDepartment of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Marc CaruanaDepartment of Anesthesia, Duke University School of Medicine, Durham, NC, USA.
Sarah A BirkenDepartment of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Background: Health-related social needs (HRSNs), including food insecurity, housing instability, transportation barriers, and financial strain, are increasingly recognized as critical to patient-centered care. Despite growing mandates and incentives to integrate HRSN screening and referral into routine clinical workflows, healthcare systems face significant challenges in implementing HRSN screening and referral processes at scale. Objectives: This study explores the early implementation of HRSN screening and referral across a multistate healthcare system, using the Health Equity Implementation Framework (HEIF) and Knowledge-to-Action (KTA) Framework to examine multilevel barriers and facilitators. Design: Qualitative descriptive design. Methods: Semi-structured interviews (n = 23) were conducted with healthcare leaders, navigators, clinicians, and community health workers (CHW), eliciting their experience with leading and implementation of HRSN screening. Results: Findings reveal that many frontline staff (including clinicians, navigators, and CHWs) reported disjointed workflows, unclear referral roles, and limited communication related to HRSN implementation. They also reported distress when screening occurred without available resources to address identified needs. CHW's explained their pivotal but under-integrated roles, serving as relational and cultural bridges between health systems and communities. All participant cohorts identified organizational and interpersonal misalignments between implementation mandates and on-the-ground realities. Suggested strategies for improvement included role-specific training, participatory design, improved integration of CHWs into care teams, feedback loops, and locally adapted referral protocols. Conclusion: These findings reinforce the value of frontline staff knowledge and experience to ensure robust implementation of HRSNs. Aligning system-level priorities with the complex realities of care delivery is essential for realizing the promise of HRSN screening as a tool for health equity.

Indexed as

community health workerhealth related social needs screeningimplementation sciencequalitative researchsocial determinants of health

Identifiers

PMID41473341
PMCPMC12745532

What Socratic holds

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LicenceCC BY-NC
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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.