Abstract

The purpose of this retrospective observation review is to evaluate the implementation of one approach to addressing unmet Social Drivers of Health (SDOH).

A 15-month, three-phase implementation of the PIN Model was conducted in a primary care ambulatory setting.

Notes

This work was supported by the DAISY Foundation Health Equity Grant Program for Addressing Social Determinants of Health (SDOH). The authors gratefully acknowledge the DAISY Foundation for its commitment to advancing evidence-based practice and promoting health equity through support of initiatives that address social drivers of health. The funding enabled the implementation and evaluation. The DAISY Foundation had no role in the study design, data collection, analysis, interpretation of findings, or manuscript/report preparation.

Author Details

Victoria Zhu, DNP, RN

Submitting author: Shelly Nawfel, BSN, RN - is a dedicated Registered Nurse (RN), bringing experience in leading a team of 6 RNs and 3 medical assistants. Her journey with Optum began with 13 years at The Polyclinic, starting as a medical assistant in primary care, where she honed her skills in patient care and clinical operations, which has led to the last 6 years with Optum Care Washington as a RN.

In her current role, she is passionate about improving healthcare outcomes through proactive community-based strategies. She oversees the day-to-day operations of the team, ensuring efficient workflow and effective coordination of care initiatives.

Sigma Membership

Non-member

Type

Article

Format Type

Text-based Document

Study Design/Type

Observational

Research Approach

Mixed/Multi Method Research

Keywords:

Social Drives of Health (SDOH), Social Determinants of Health, Care Coordination, Medical Case Management, Population Health Navigation, Primary Health Care, Primary Care, Outpatient Medical Care

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Submitted for Open Dissemination

Acquisition

Self-submission

Date of Issue

2026-10-06

Full Text of Presentation

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Funder

The DAISY Foundation

Download

Available for download on Thursday, April 06, 2028

Click on the above link to access the paper.

Additional Files

Report.pdf (105 kB)

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