title: Integrating social context into comprehensive shared care plans: A scoping review.
abstract: Failure to address social determinants of health (SDH) may contribute to the problem of readmissions in high-risk individuals. Comprehensive shared care plans (CSCP) may improve care continuity and health outcomes by communicating SDH risk factors across settings.
  
  
  
  The purpose of this study to evaluate the state of knowledge for integrating SDH into a CSCP. Our scoping review of the literature considered 13,886 articles, of which seven met inclusion criteria.
  
  
  
  Identified themes were: integrate health and social sectors; interoperability; standardizing ontologies and interventions; process implementation; professional tribalism; and patient centeredness.
  
  
  
  There is an emerging interest in bridging the gap between health and social service sectors. Standardized ontologies and theoretical definitions need to be developed to facilitate communication, indexing, and data retrieval.
  
  
  
  We identified a gap in the literature that indicates that foundational work will be required to guide the development of a CSCP that includes SDH that can be shared across settings. The lack of studies published in the United States suggests that this is a critical area for future research and funding.
authors.affiliation: School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. Electronic address: suzanney@buffalo.edu.
authors.forename: Suzanne S
authors.initials: SS
authors.lastname: Sullivan
authors.affiliation: School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY.
authors.forename: Francine
authors.initials: F
authors.lastname: Mistretta
authors.affiliation: Department of Industrial and Systems Engineering, University at Buffalo, The State University of New York, Amherst, NY.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Casucci
authors.affiliation: School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY.
authors.forename: Sharon
authors.initials: S
authors.lastname: Hewner
mesh_terms: D000328:Adult; D003142:Communication; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration*; D012307:Risk Factors; D064890:Social Determinants of Health; D012931:Social Environment; D014481:United States
keywords: Coordinated care; Health information exchange; Interdisciplinary communication; Patient care planning; Social determinants of health