An Innovative Nurse Navigator Approach to Screen For and Address Social Needs in a Veterans Health Administration Women s Health Clinic #MMPMID41359993
Daus M; Pfeiffer L; Kennedy MA; Piazza KM; Cohen AJ; Agnew J; Hinkle P; Igo S; Halladay CW; Leder SM; Mitchell KM; Moy E; Nestman K; Ruggles S; Russell LE
Med Care 2026[Jan]; 64 (1S Suppl 1): S82-S90 PMID41359993show ga
BACKGROUND: Women Veterans are the fastest-growing population in the Veterans Health Administration (VHA), but little is known about how to identify and address their social needs. This program evaluation examined the implementation of a social screening and referral initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), using nurse navigators in a VHA women's health clinic. OBJECTIVES: (1) Describe the implementation process and outcome measures, (2) assess the prevalence of women Veterans' social needs, (3) characterize nurse navigators' perceptions of ACORN, and (4) document implementation challenges and adaptations. RESEARCH DESIGN: Program evaluation with qualitative and quantitative data collected between March 2023 and November 2024. Descriptive statistics were used to summarize sociodemographic characteristics and social needs of Veterans screened. SUBJECTS: Veterans receiving continuity care at a women's health clinic in a midwestern VHA hospital. RESULTS: Nurse navigators completed ACORN screens with 291 Veterans, with 67% screening positive. The most frequently reported needs were social isolation/loneliness (49%), utilities (17%), transportation (14%), and digital needs (13%). Nurse navigators and the nurse site champion reported that ACORN enhanced their understanding of patients' social needs and their ability to address these needs. They also reported seamless integration of ACORN into existing workflows. CONCLUSIONS: Findings show early insights into women Veterans' unique social needs. An innovative nurse navigator approach to social screening in a VHA women's health clinic was feasible, had high likelihood of sustainment, and improved nurses' ability to care for their patients. This indicates strong potential for expanding nurse navigator roles both within and outside VHA.
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Med+Care 2026 ; 64 (1S Suppl 1): S82-S90
