Impact of Social Needs Screening on Hypertension
August 21, 2025
Read a Q&A Below
Ado Rivera, PhD and the team at Northwestern University’s Feinberg School of Medicine Department of Medical Social Sciences (MSS) received a grant from the American Heart Association titled: "Mixed Methods Study on Impact and Implementation of Social Needs Screening and Referral on Hypertension Outcomes." Co-investigators include Nori Allen, PhD, Cynthia Barnard, PhD, MBA, Lauren Beach, PhD, JD, Shahin Davoudpour, PhD, and Callie Walsh-Bailey, PhD.
What are the aims of the project?
We are studying the impact and implementation of social needs screening and referral in an academic health system context (Northwestern Medicine). This intervention intends to support patients with health-related social needs by giving patients a list of community resources or organizations that can address those needs. Our first aim will look at the patient’s experience in navigating this system, assess if they engage with organizations, and test if the intervention influences their hypertension outcomes. Our second aim will look at the community organizations and their role in patient outcomes. Our third and integrative aim will bring together patients, community organization representatives, and Northwestern Medicine to examine implementation bottlenecks and potential strategies to improving the process.
What are your next steps?
This is a three-year project that will involve surveys and qualitative interviews of patients and community-based organizations, analysis of electronic health records, and a series of implementation mapping workshops.
We are currently developing the patient survey to send out to patients with the aim of starting collection in September 2025. In the near-term, we will also be extracting the names of organizations from the community resource lists and pulling data about them from administrative sources. This would help us develop our organizations survey.
What do you hope will come out of this funded research?
The immediate goal is to answer the question: Do these screening and referral programs impact clinical health outcomes? Why or why not? I think answering this question can help health systems make sure that this program translates to actual patient benefits. This also helps refine the model of social care integration where health systems take a more active role in addressing patient needs that do not directly stem from their illnesses. We think we can use this study to inform future multi-site studies on social care integration. We also want to leverage this work to launch collaborations with clinical researchers to study interventions on social needs in other diseases.
I also hope that we can use this project to launch other studies that aim to understand meso-level drivers of health. A lot of health and social services are delivered through local or regional organizations. I would be interested to see how changes in these organizations influence the health of communities that they serve.