Abstract

Background: Social barriers such as transportation insecurity, food instability, and limited social support are well-documented contributors to poor transplant outcomes, yet outpatient transplant programs often lack reliable mechanisms to identify these needs at the population level. 
Local Problem: A large outpatient transplant clinic had an existing electronic health record Social Determinants of Health (SDOH) screening tool that was inconsistently used, leaving social need data largely inaccessible for quality monitoring. 
Intervention: Five transplant social workers received targeted education on seven SDOH domains, flowsheet navigation, and documentation expectations, paired with ongoing monitoring and coaching to reinforce consistent completion. 
Methods: This quality improvement project used a pre/post design within a single Plan-Do-Study-Act cycle. Aggregate, de-identified electronic health record data were analyzed descriptively across a 12- week tracking period. Institutional review board exempt determination was granted under Category 4. 
Results: Of 371 outpatient encounters, 241 (65.0%) included a completed SDOH flowsheet, exceeding the 50% target. Social Connections had the highest positivity rate (41.7%), followed by Stress (29.8%), Food Insecurity (19.5%), and Transportation Needs (16.0%). Staff knowledge scores improved from 85% to 95%. 
Conclusions: Standardizing an existing outpatient SDOH screening tool is feasible using current staff and infrastructure at no additional cost. Social work-led documentation is sustainable and applicable across outpatient transplant programs.

Date of publication

Fall 2026

Document Type

DNP Scholarly Project

Language

english

Persistent identifier

http://hdl.handle.net/10950/5213

Committee members

Emily Fox, Angie (Mary) McClnnis, Jennifer Chilton

Degree

Doctor of Nursing Practice

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