{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T02:50:13Z","timestamp":1789095013146,"version":"build-2803163510"},"reference-count":41,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"name":"Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery at Mayo Clinic"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J Prim Care Community Health"],"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction\/Objectives<\/jats:title>\n                    <jats:p>The rise in screening for social drivers of health (SDoH) in primary care settings has led to questions about effective intervention design. A large primary care practice at Mayo Clinic developed a model centered on a full-time Health Equity Coordinator (HEC) to facilitate clinic-community partnerships in 2022. The goal of this analysis was to assess the model on process outcomes, resolution of SDoH needs, and changes in healthcare utilization.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using a cohort study design, we identified primary care patients with unmet SDoH needs at the intervention clinic and two comparator clinics from March 2022 to December 2023. We assessed process outcomes descriptively and resolution of SDoH needs and healthcare utilization using multivariable regression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The HEC contacted 348 patients and conducted 748 meetings with community-based organization staff. While there were decreases for SDoH needs and missed or late cancelled appointments in intervention group, there were no significant difference in resolution of SDoH and healthcare utilization relative to comparator groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The HEC model for multi-stakeholder coordination showed promise in referring patients to services and engaging key stakeholders in a primary care setting. Longer term follow up may be needed to identify changes in SDoH needs and healthcare utilization.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/21501319261472633","type":"journal-article","created":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T23:28:52Z","timestamp":1785281332000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Coordinating Multisector Efforts to Address Social Needs in a Rural Midwestern Primary Care Setting"],"prefix":"10.1177","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3190-7740","authenticated-orcid":false,"given":"Samuel T.","family":"Savitz","sequence":"first","affiliation":[{"name":"Mayo Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3281-6234","authenticated-orcid":false,"given":"Margaret M.","family":"Paul","sequence":"additional","affiliation":[{"name":"Mayo Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gretchen E.","family":"Mauerman","sequence":"additional","affiliation":[{"name":"Mayo Clinic Health System Southwest Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy E.","family":"Glasgow","sequence":"additional","affiliation":[{"name":"Mayo Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah B.","family":"Harper","sequence":"additional","affiliation":[{"name":"Mayo Clinic Health System"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica J.","family":"McCoy","sequence":"additional","affiliation":[{"name":"Mayo Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8563-340X","authenticated-orcid":false,"given":"Erin C.","family":"Westfall","sequence":"additional","affiliation":[{"name":"Mayo Clinic Health System Southwest Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,7,28]]},"reference":[{"issue":"165","key":"e_1_3_5_2_2","first-page":"58640","article-title":"Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2024 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Rural Emergency Hospital and Physician-Owned Hospital Requirements; and Provider and Supplier Disclosure of Ownership; and Medicare Disproportionate Share Hospital (DSH) Payments: Counting Certain Days Associated With Section 1115 Demonstrations in the Medicaid Fraction","volume":"88","author":"Centers for Medicare & Medicaid Services (CMS), HHS","year":"2023","unstructured":"Centers for Medicare & Medicaid Services (CMS), HHS. 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