A Practical Approach to Screening for Social Determinants of Health
Screening patients to understand their social context is the gateway to addressing barriers and improving health.
Fam Pract Manag. 2018 May-June;25(3):7-12.
Author disclosures: no relevant financial affiliations disclosed.
Decades ago, the historic Whitehall studies demonstrated the impact that social context can have on individuals' health and wellbeing.1,2 Family physicians understand this well because they see firsthand how social needs (or “social determinants of health”) create access, adherence, or performance barriers, often impeding their efforts to provide evidence-based clinical care that improves overall health.3,4 For example, a patient who lacks safe housing, reliable transportation, or adequate food resources may struggle with medication adherence or getting to visits on time.
The ecology of medical care5 and the current financing system, which tend to focus on health care as opposed to health, may limit physicians' ability to address social context. Nevertheless, family physicians can take practical steps to address social determinants of health in their practices. This article will discuss the concerns and challenges related to screening for social determinants of health and offer several tools and recommendations.
Patients' social needs related to housing, food, safety, etc., can create significant obstacles to high-quality care and contribute to poor health.
Screening for social determinants of health without first equipping the practice to address identified needs would be ineffective and unethical.
Several brief screening tools can be effective in primary care practices as part of a workflow designed to address social needs with referrals to community-based resources.
TO SCREEN OR NOT TO SCREEN
Despite studies demonstrating the impact of socioeconomic factors on health, there is no evidence-based screening recommendation for social determinants of health from an organization such as the U.S. Preventive Services Task Force. Even without a formal recommendation, several policy statements support such screening,6,7 and a current national initiative through the Centers for Medicare & Medicaid Services (CMS), the Accountable Health Communities Model,8 may soon shed evidence on the impact of screening. Additionally, community health centers have been screening for social determinants of health and coordinating related services for years. Their experiences have suggested some best practices for developing “medical neighborhoods,” particularly in underserved and diverse communities.
Concerns about the limited research for screening for social determinants of health are understandable, but they reveal our implicit bias against information from sources other than randomized controlled trials (RCTs).9 Although RCTs rely on standardization, consistency, and fidelity of the intervention, community-based research on community-level health interventions must rely on variation to deliver interventions in the field to tailor
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