Background: Despite the increased awareness of social determinants of health (SDoH), integrating social needs screening into health care practice has not consistently occurred.
Local Problem: No social needs screening using recommended standardized questions was available at an outpatient hemodialysis clinic.
Methods: Plan-Do-Study-Act cycles, based on the Model for Improvement, were used to implement the Core 5 SDoH screening tool, a staff referral process, and an evaluation of the implementation process.
Intervention: A standardized social needs screening tool and a staff referral process were implemented. An evaluation of the implementation process also occurred.
Results: Of 73 patients screened, 21 reported 32 unmet social needs; all received referrals to community resources. Nurses demonstrated high acceptance and usability of the tool and the referral process.
Conclusions: Implementing a standardized screening and referral process customized to clinical workflow enhanced the identification of social needs in patients undergoing hemodialysis.
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