Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico

J Am Board Fam Med. 2016 May-Jun;29(3):414-8. doi: 10.3122/jabfm.2016.03.150272.


Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients' social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients.

Keywords: Clinical Medicine; Primary Health Care; Social Determinants of Health; Social Problems.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Community Health Workers / economics
  • Community Health Workers / legislation & jurisprudence*
  • Family Practice / legislation & jurisprudence
  • Family Practice / methods*
  • Feasibility Studies
  • Health Policy
  • Humans
  • Insurance, Health, Reimbursement
  • Medicaid
  • New Mexico
  • Pilot Projects
  • Primary Health Care / legislation & jurisprudence
  • Primary Health Care / methods*
  • Referral and Consultation
  • Social Determinants of Health*
  • Socioeconomic Factors
  • Surveys and Questionnaires
  • United States