A Scoping Review of Guidelines and Quality Measures to Screen for Social and Caregiver Support and Cognitive Impairment in Primary Care

High-risk patients—those patients with complex health care needs who are most likely to face hospitalization or death in the following two years—are most often initially seen in the primary care setting. This small group of patients uses a disproportionate amount of care resources. Contributing to the challenges of care planning for this population is that individuals are highly heterogeneous; no two patients present the same set of symptoms, diagnoses, and challenges related to social determinants of health (SDOH). Methods for early identification of these high-risk patients—and their care needs—have raised the possibility of timely enhanced care. In this study, the authors conduct a scoping review to identify existing measures of care quality; assessment and screening guidelines; and tools that (1) assess social support, the need for caregiver support, and the need for referral to social services and (2) screen for cognitive impairment (CI). Evidence-based screening guidelines define who and what should be assessed—and how often—to enhance care quality and improve health outcomes, whereas measures permit ascertainment that this assessment is occurring. Evidence-based guidelines and measures—those that are found to lead to better health care outcomes—would be candidates for inclusion in a measure dashboard for high-risk patients in primary care settings.