Research Mentor Name

Robert Sherwin, M.D.

Research Mentor Email Address

Institution / Department

Cass Clinic

Document Type

Research Abstract

Research Type


Level of Research



Background/Problem Statement

The Cass Clinic in Detroit, MI is a student-run free clinic (SRFC) that provides care for an underserved, underrepresented population. Our patients experience a high incidence of chronic health conditions accompanied by poverty, homelessness, and food insecurity which complicate care. Integrating social well-being into primary care creates a two-pronged approach to improving patient outcomes: medical care and disease prevention. A social needs program was implemented at Cass Clinic in order to address such social determinants of health.


A social needs screening modality was created and integrated into a medical encounter triage form. Two AAFP social needs screening questions were asked to identify and triage patients who may benefit from social needs services. After triage, patients were connected with social needs personnel to assist with personally identified short or long-term goals, such as obtaining a bus pass or low-income housing assistance.


Implementation of this initiative was achievable with limited challenges. Of all patients surveyed (n=12), 42% reported concern at least some of the time with their current food and/or housing situation. All patient social needs visits (n=4) addressed diverse social determinants of health including housing insecurity (n=4), clothing (n=3), food insecurity (n=2), and bus pass/transportation (n=1).


To provide holistic healthcare and assist in the long-term management of chronic medical conditions, SRFC should identify and address social determinants of health. Integrating social well-being serves a vital role in the prevention and management of chronic health conditions.


Medicine and Health Sciences