Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Date of Graduation


Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing


Holly A. Buchanan, DNP, MS, RN, ANP-BC

Lauren James, MD


Social determinants of health (SDOH) screening and referral programs are crucial to achieving health equity, fundamental to providing the best care, and are critical to the United States’ pursuit of the Institute for Healthcare Improvement’s (IHI) Triple Aim (Berwick et al., 2008). Employing the PRECEDE-PROCEED model, a systematic screening and referral program was implemented at a safety-net clinic to increase SDOH screening and referral rates, and to identify the number of patients who connect with community resources. The program was guided by the IHI Triple Aim framework and evaluated using the Institute of Medicine (IOM) Six Aims of Healthcare Quality evaluative criteria (Institute of Medicine, 2001).

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