Developing a pragmatic guide to implementing social risk referrals: A partnership between Caring Health Center (CHC) and the Implementation Science Center for Cancer

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PROJECT SUMMARY This supplement is a collaborative effort across four ISC3 Centers: BRIDGE-C2, Harvard ISCCCE, University of Washington OPTICC, and Washington University-ISC3. ISCCCE collaborates with a network of community health centers (CHCs), which serve as its implementation laboratory. CHCs face some of the most difficult implementation challenges as they primarily serve patients with high social needs. Addressing patients’ social needs is a critical part of enabling patients to access evidence-based cancer screening and prevention interventions. Well-documented challenges in addressing social needs include determining how best to maintain up-to-date information about available service agencies to which persons with social needs may be referred, and developing and adopting optimal workflows for doing so. Social service resource locators (SSRLs) that identify currently available resources take varying forms ranging from a social worker maintaining a hard-copy binder of resources to an informatics platform integrated into the electronic health record (EHR) and designed to enable bidirectional communication with local organizations about referred patients’ receipt of services (also called community resource referral platforms). Building on the findings from the Phase I supplement, we propose to: (1) develop a pragmatic, applied guidebook (the Guide) for clinics seeking to implement or expand efforts to address patient-reported social risks using Assistance strategies; (2) use rapid- cycle testing to identify best practices for implementing the Guide; (3) iterate and disseminate the refined Guide; and (4) create a toolkit to package learning from the prior Phase 1 Health Equity Supplement along with that from the ISC3 Phase 2 projects, and make the toolkit available through the NCI.