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ORCID
https://orcid.org/0009-0001-3696-0498
Date of Graduation
12-13-2025
Semester of Graduation
Fall
Degree Name
Doctor of Nursing Practice (DNP)
Department
School of Nursing
First Advisor
Erica Lewis
Abstract
Social drivers of health (SDOH), non-medical factors such as economic stability, education, community support, and access to food and healthcare, affect health outcomes worldwide. People experiencing homelessness face disproportionate health burdens: they have a shorter life expectancy, are less likely to receive primary and preventive care, and are more likely to receive care in acute care or emergency room settings than those who have stable housing. This not only contributes to health problems but also leads to increased costs due to a lack of prevention and patients being sicker by the time they are seen in a healthcare setting. SDOH screening could enable healthcare teams to determine the population’s needs and facilitate timely referrals. This quality improvement (QI) project was completed at a clinic for the unhoused in a town in the Southeast. In early 2025, the clinic initiated a process change implementing the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) tool to screen patients for SDOH and connect those with unmet needs to local resources. Anonymized, retrospective data were collected from the screening and referral process to analyze the overall screening rate, rates of unmet social needs, and referral rates and types. Qualitative feedback from physician assistant students implementing the screening was collected to determine strengths and weaknesses of the process, informing improvements to the referral resources. Of 102 patients, 30 (29.41%) were screened. The most common unmet needs were access to food and transportation (each n = 14, 46.67%). The most common referrals provided were for mental health resources (n = 6, 20%) and transportation (n = 4, 13.33%). Student feedback on the process indicated that they found the screening process beneficial; however, they felt they needed more education on the referral process. Future efforts should focus on increasing screening rates, strengthening the referral process, and tracking patient follow-through with provided resources.
