Reducing Screening Disparities for Social Drivers of Health

At UMass Memorial Health, we screen our patients for Social Drivers of Health (SDOH) to identify and address factors that impact patients’ overall well- being, such as housing, food security and access to care. SDOH screening at UMass Memorial began in 2024, and early results showed a disparity of screening rates between white patients and patients of color. In fiscal year 2025, our Health Equity True North project team set out to reduce this gap.

By addressing the screening gap, health systems like ours aim to ensure that everyone benefits equitably. This focused effort supports lasting health equity, allowing us to help where disparities persist and improve outcomes for those most affected by social and economic challenges.

A multidisciplinary team of caregivers, practice managers and health equity leaders led the initiative. Fifteen of our primary care practices were prioritized for more focused interventions, supported by systemwide efforts to ensure changes were sustainable. These interventions included one-on-one discussions with practice managers and physician champions, dedicated training sessions, and sharing ideas from high-performing practices.

Thanks to the hard, thoughtful work by our teams, by the end of FY25, we had reduced the racial gap in the SDOH screening gap by 30%.

Two practices stood out for their efforts throughout the year: Winthrop Street Internal Medicine and Pediatric Primary Care-Benedict. These practices embraced the challenge and implemented several strategies for improvement, including conducting reviews of their current workflows, providing refresher trainings for staff, and even engaging a Unit Based Team, a voluntary group of managers and frontline staff who work on process improvement projects to implement change for their department.

“Our efforts to reduce the screening gap will continue through the implementation of innovative and effective interventions across the system,” said Arvin Garg, MD, MPH, Associate Chief Quality Officer for Health Equity at UMass Memorial Health. “SDOH screening is essential to advancing health equity by addressing unmet basic needs which we know are intrinsically linked to our patients’ health outcomes.” •