February 13, 2018
3 min read

AAFP develops tool for PCPs to help patients reach maximum health potential

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Julie Wood
Julie K. Wood

AAFP recently launched The EveryONE Project, which includes a toolkit designed to help family physicians assess the social determinants of health in their patients and help them obtain “optimal health outcomes.”

The social determinants of health are conditions such as education, access to food, transportation and safety in home, that go beyond screening, diagnosing and treating health conditions, according to Julie K. Wood, MD, MPH, the Academy’s senior vice president of health of the public and interprofessional activities.

“We have known for some time that the social determinants of health have an impact on the health of our patients,” Wood told Healio Family Medicine. “The short amount of time we spend with our patients in the office or other clinical settings is one thing, but 80% of what happens to our patients, happens as a result of something outside the office and has a big impact on their health.”

A recent survey indicated that 83% of AAFP members agreed that they should ascertain and help manage their patients’ social determinants of health, but almost as many said they did not have time to discuss these conditions with their patients.

Art Kaufman
Art Kaufman

Addressing the social determinants of health rapidly becoming the new way to provide patient care, according to Arthur Kaufman, MD, professor and vice chancellor, University of New Mexico School of Medicine.

“Most health systems still make money the old-fashioned way by performing procedures and hospitalizing patients, but that’s not the way of the future,” he told Healio Family Medicine. “You can’t just screen, you have to intervene. The future is by caring for and managing populations and keeping them healthy and [The EveryONE Project toolkit] is one of the critical tools for doing that.”

The first part of the toolkit has two forms, both of which ask about personal safety, utilities, transportation, food and housing, Wood said. A longer form asks about financial strain, child care, education and employment. According to the Academy, the questions have been “tested, validated and purposefully assembled to reveal the health hurdles that patients are facing.”

One form is provided to the doctor and the other to the patient, with the doctor’s version including instructions on how to handle a ‘positive’ screen’, Wood said.

Every question does not need an answer, she added.

“Practices that opt to screen for only one item, such as food insecurity, can pull out the individual questions.”


Mindful of studies that suggest primary care physicians are already overwhelmed with administrative tasks, she added that The EveryONE Project toolkit is not intended to increase a clinician’s existing workload.

“Our goal is not to put the entire burden on the family physician, but rather involve the whole office team, and also tap into community resources that address the social determinants of health. We don’t want to add a lot of time to the physician’s day, we want to support patient care, which can lead to better health outcomes.”

Kaufman was not directly involved with AAFP’s The EveryONE Project but said initiatives like it can produce positive, far-reaching results not always found in the traditional medical office, such as helping students graduate from high school, families staying in their homes or adults remaining gainfully employed.

“People always wonder why the U.S. spends more on its health system than any other western country but has by far the worst outcomes?” he said in the interview. “If you look at the amount spent, the U.S. spends far more on the health service system as opposed to the social service system. AAFP caught up with everyone with this toolkit.”

The second part of the toolkit will be launched in the spring, and “will focus on a team-based approach to screening for social determinants of health and resources to efficiently implement this work in a family medicine practice,” according to Wood.

The next phase will also have tools to ascertain if a practice can intervene after determining a patient’s needs as they relate to the social determinants of health, evaluate community needs that would best provide referral resources and ways to create partnerships with local behavioral and social health resources to supplement the screening and referral process, according to the Academy.

Additional releases of the toolkit are scheduled throughout the year and will be complete by the end of 2018, she said, adding that another survey will be taken later this year to assess members’ response to the toolkit. – by Janel Miller

For more information:

AAFP.org. “The EveryONE Project.” https://www.aafp.org/patient-care/social-determinants-of-health/cdhe/everyone-project/tools.html. Accessed Feb. 2, 2018.

Disclosure: Wood is AAFP's senior vice president of health of the public and interprofessional activities. Kaufman reports no relevant financial disclosures.