Assessing the contextual factors around implementing social needs screening and intervention programs in primary care in the United States: A systematic review.

Objective

To summarize the contextual factors influencing implementation of US-based social needs screening and intervention programs in primary care.

Methods

We searched CINAHL, Cochrane, Ovid, PubMed, and Scopus (January 2015-April 2025). Included studies reported on programs using a structured tool to screen adult patients for and address social needs in US-based primary care settings. Data were summarized narratively, guided by the Practical, Robust, Implementation, and Sustainability Model (PRISM) framework.

Results

Twenty-nine studies (41 articles) were included. Successful implementation of social needs programs was associated with standardized yet adaptable workflows, dedicated multidisciplinary staff, leadership support, staff training, practice champions, and strong coordination with community organizations. Common barriers included limited time, staffing shortages, high screening-related caseloads, workflow and referral-tracking challenges, and insufficient community resource availability. Patients generally valued receiving social care in primary care and emphasized the importance of ongoing screenings, individualized assistance, navigation support, timely follow-up, and building trust.

Conclusions

Primary care-based social needs programs were generally valued but required careful integration into existing clinical and organizational processes. Adequate staffing capacity, integrated workflows, adaptable protocols, and sustainable financing appear critical for long-term success. Future efforts should incorporate implementation and sustainability planning early to improve program feasibility, reach, and impact.