Integrating Social Risk Factor Screening in Cancer Survivorship Care: Insights From a Qualitative Study

This summary provides an overview of findings from the published study, “Contextual Factors Relevant to Implementing Social Risk Factor Screening and Referrals in Cancer Survivorship: A Qualitative Study,” originally appearing in Preventing Chronic Disease, which explores the current gaps, barriers, and opportunities in implementing social risk factor screening and referral processes across oncology settings.

Introduction

This study investigates the implementation of social risk factor screening and referral processes in cancer survivorship care within 3 oncology settings in Washington, DC. Social risk factors, such as food insecurity, transportation issues, and financial strain, are known to negatively affect health outcomes. However, systematic screening and referral processes to address these factors are limited in oncology settings, particularly during the survivorship phase of care. The study aims to explore current workflows, barriers, and opportunities for integrating social risk factor screening into survivorship care using qualitative data from interviews conducted with oncology staff and providers.

The research highlights disparities in health outcomes caused by social determinants of health, emphasizing the need for strategies to address these factors in survivorship care. Survivorship is a critical phase in the cancer care continuum, as patients often face ongoing challenges related to financial toxicity, social isolation, and access to resources. The study is part of a broader initiative to reduce health disparities among cancer patients in Washington, DC.

Methods

The study utilized semistructured interviews with 18 oncology staff members, including clinical providers (oncologists, nurse practitioners, physician assistants, and nurse navigators) and support staff (social workers, patient navigators, and patient advocates). Participants were recruited from 3 health systems serving a large proportion of historically marginalized patients, including those from lower socioeconomic backgrounds and Black patients. The interviews were conducted in February and March 2022 and analyzed using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

The EPIS framework guided the interview process and analysis by focusing on:

1. Outer Context: Environmental and policy factors affecting social risk factor screening.
2. Inner Context: Organizational characteristics, staffing, and workflows.
3. Bridging Factors: Relationships with community-based organizations and external resources.

Data were coded and analyzed to identify recurring themes, barriers, facilitators, and recommendations for implementing social risk factor screening and referral processes.

Results

The study revealed significant gaps in survivorship care related to social risk factor screening and referrals. Key findings are summarized below.

1. Lack of Standardized Survivorship Programs
   None of the participating institutions had a formal program to identify cancer survivors or systematically address their social needs. Survivorship care pathways varied widely depending on cancer site, treatment type, and institutional resources. For example:
   • Patients completing curative treatments (eg, surgery, chemotherapy, radiation) were not consistently transitioned to survivorship care
   • Providers often relied on manual tracking or direct communication to coordinate posttreatment care, as survivorship status was not systematically documented in electronic health records (EHRs)
2. Awareness of Social Risk Factors
   Participants acknowledged the prevalence and impact of social risk factors on cancer survivors. Common challenges included food insecurity, transportation barriers, financial toxicity, and social isolation. Despite this awareness, none of the institutions had a systematic process for screening and addressing these needs.
3. Barriers to Implementation
   Several barriers to social risk factor screening and referrals were identified:
   • Staffing Limitations: Clinics lacked dedicated personnel to screen for social risks or manage referrals. Existing staff, such as social workers and navigators, were often overburdened with other responsibilities
   • EHR Challenges: Documentation and tracking of social risk factors and referrals were inconsistent across institutions. Two clinics had recently transitioned to new EHR systems, creating competing priorities and challenges in integrating social care workflows
   • Community Resource Constraints: Participants expressed concerns about the availability and reliability of community-based resources. Eligibility criteria for services were often unclear, and maintaining up-to-date referral directories was challenging
   • COVID-19 Impacts: The pandemic exacerbated staffing shortages, increased patient social needs, and disrupted team-based care structures
4. Variability Across Institutions
   The 3 participating institutions differed in their approaches to survivorship care and social risk factor screening:
   • Two institutions offered site-specific cancer care, while 1 provided general oncology services
   • Social care workflows varied depending on institutional resources, staffing, and accreditation standards
   • Referral processes often relied on informal networks or outdated lists of community organizations rather than standardized databases or systems
5. Opportunities for Improvement
   Despite the barriers, participants identified several opportunities to improve social risk factor screening and referrals:
   • Dedicated Staffing: Designating personnel to manage social care activities, such as screening and referrals, could reduce the burden on existing staff and improve care coordination
   • EHR Optimization: Enhancing EHR systems to track survivorship status, social risk factors, and referral outcomes would streamline workflows and improve data sharing across teams
   • Community Partnerships: Building stronger relationships with local organizations and maintaining up-to-date referral directories could facilitate timely and effective resource access for patients
   • Closing the Referral Loop: Clinics should develop systems to track whether referrals are completed and whether patients’ needs are addressed

Discussion

The study highlights the complexity of implementing social risk factor screening and referral processes in cancer survivorship care. Key themes include the need for tailored approaches to address institutional differences, the importance of dedicated staffing, and the role of EHR systems in facilitating data tracking and communication.

1. Social Determinants of Health
   Social determinants of health play a significant role in shaping cancer survivorship outcomes. Survivors often face ongoing challenges related to financial toxicity, social isolation, and access to resources. Addressing these factors is critical for improving health equity and patient quality of life.
2. Institutional Challenges
   The lack of standardized survivorship programs and the variability in workflows across institutions underscore the need for tailored solutions. Differences in treatment trajectories, staffing, and accreditation standards complicate efforts to implement universal screening processes.
3. Role of EHR Systems
   EHR systems are essential for tracking social risk factors, referrals, and survivorship status. However, the study found that existing EHR systems were often inadequate for these purposes. Enhancing EHR functionality and integrating social care workflows could improve data tracking and communication.
4. Staffing and Resource Allocation
   Dedicated roles for social care activities, such as patient navigators or community health workers, could address the staffing limitations identified in the study. These roles would ensure that social risk factor screening and referrals are consistently implemented without overburdening existing staff.
5. Community Partnerships
   Strong relationships with community-based organizations are critical for addressing patients’ social needs. Clinics should prioritize maintaining up-to-date referral directories and improving communication with external resources to ensure patients receive appropriate support.

Conclusion

The study identifies significant gaps in survivorship care related to social risk factor screening and referrals. Addressing these gaps requires tailored approaches that account for institutional differences, staffing realities, and patient needs. Key recommendations include:

• Developing systematic workflows for identifying cancer survivors and screening for social risk factors
• Investing in EHR optimization to track referrals and outcomes
• Allocating resources for dedicated staff to manage social care activities
• Building stronger relationships with community-based organizations to ensure timely and effective referrals

While the study focuses on oncology settings in Washington, DC, its findings are broadly applicable to community oncology clinics. Implementing social risk factor screening and referral processes could improve survivorship care, reduce health disparities, and enhance patient outcomes.

Reference

1. Astorino JA, Pratt-Chapman ML, Schubel L, et al. Contextual factors relevant to implementing social risk factor screening and referrals in cancer survivorship: a qualitative study. Prev Chronic Dis. 2024;21:230352.