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.