NEJM Interview: Danielle Jones on the Development of Tools to Help Family Physicians Address Soci...

Why It Matters

The toolkit equips frontline physicians with actionable data to mitigate health disparities, while highlighting systemic barriers that must be addressed for equitable care to become routine.

Key Takeaways

• AFP created Everyone Project to embed health equity tools in primary care.
• Survey identified physicians' frequent social determinant queries: food, housing, transport.
• Toolkit offers multilingual screening questions and resource guides for community linkage.
• Implementation hindered by workflow integration, EHR compatibility, and feedback loops.
• Policy advocacy and system redesign essential for sustainable health equity impact.

Summary

The interview with Danielle Jones, vice president of accountability at AWHONN, discusses the American Academy of Family Physicians' "Everyone Project"—a decade‑old toolkit designed to help primary‑care doctors screen for and address social determinants of health.

The project began with an AAFP‑wide environmental scan that surveyed physicians about the frequency of social‑determinant encounters and their confidence in intervening. Systematic literature reviews distilled a core set of questions—food security, housing stability, transportation, medication access, clean water—into a multilingual screening form now hosted on afp.org/everyone.

Jones notes that early adoption was hampered by paper‑based workflows, limited EHR integration, and a missing feedback loop to track whether referrals improved outcomes. Over ten years, additional modules on implicit bias, community partnership, and practice‑level policy change have been layered onto the original resource.

The conversation underscores that lasting health‑equity gains will require organizational buy‑in, interoperable data systems, and policy advocacy that makes equitable choices the default. For family physicians, the toolkit offers a practical bridge between clinical encounters and broader social interventions, but scaling it depends on systemic reforms.

Original Description

Danielle Jones is the vice president of accountability, belonging, and culture at the Association of Women's Health, Obstetric and Neonatal Nurses. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. W.T. Moore and Others. From Clinic to Community — The EveryONE Project in Family Medicine. N Engl J Med 2026;394:1353-1354.