Caring for the Underserved: Addressing A Community's Social Needs Without a Social Worker


Mid America


Research Medical Center

Document Type


Publication Date



community health, community resources, quality improvement, social determinants of health


Community Health | Family Medicine | Mental and Social Health


Goppert Trinity Family Care Clinic (GTFCC) is a community-based Family Medicine Residency Clinic in the heart of Kansas City, Missouri that serves, amidst others, an underserved patient population. In the absence of a social worker, it is still imperative to assess and address the social needs of the clinic's patients in order to positively impact their health outcomes. The clinic adapted a quality improvement project that utilized AAFP's EveryONE project. This project used AAFP's evidence based tools for assessing patients' social determinants of health (SDOH) as well as an online search engine ( to identify existent community resources that would help address the identified social needs. Through this presentation, the presenters hope to share GTFCC's experiences and help the audience meet the objectives stated below.

Upon completion of this session, participants should be able to:

  1. Define and identify the social determinants of health
  2. Assess patients' social needs during regular office visits using the evidence based screening tool from AAFP's EveryONE Project
  3. Identify and maintain a directory of community based resources that match their patients' identified social needs

Publisher or Conference

Society of Teachers of Family Medicine Conference on Practice & Quality Improvement