PULSE DeveloPing a pragmatic gUide to impLementing social riSk assistancE

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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 (WU)-ISC3. Addressing patients’ social needs is a critical part of enabling patients to access evidence-based cancer screening and prevention interventions, a focus of the WU-ISC3 Center. 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 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; and (3) iterate and disseminate the refined Guide. WU-ISC3 will test the guide in Missouri Highlands Health Care, a Federally Qualified Health Center in rural southern Missouri, who face some of the most difficult implementation challenges as they primarily serve patients with high social needs and are located in an outer context with fewer resources than urban areas.