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.

KEY POINTS

  • 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

ABOUT THE AUTHORS

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Dr. O'Gurek is an assistant professor in the Department of Family and Community Medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia....

Dr. Henke serves as chief medical officer of Community of Hope, a community health center in Washington, D.C.

Author disclosures: no relevant financial affiliations disclosed.

References

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6. Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records, Board on Population Health and Public Health Practice, Institute of Medicine. Capturing Social and Behavioral Domains and Measures in Electronic Health Records. Washington, DC: National Academy of Medicine; 2014. http://www.nap.edu/catalog/18709/capturing-social-and-behavioral-domains-in-electronic-health-records-phase. Accessed March 8, 2018.

7. Council on Community Pediatrics, American Academy of Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339.

8. Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable health communities – addressing social needs through Medicare and Medicaid. N Engl J Med. 2016;374(1):8–11.

9. Newman TB, Kohn MA. Evidence-Based Diagnosis. New York, NY: Cambridge University Press, 2009.

10. Braveman PA, Egerter SA, Woolf SH, Marks JS. When do we know enough to recommend action on the social determinants of health? Am J Prev Med. 2011;40(1):S58–S66.

11. Briss PA, Brownson RC, Fielding JE, Zaza S. Developing and using the Guide to Community Preventive Services: lessons learned about evidence-based public health. Annu Rev Public Health. 2004;25:281–302.

12. Perrin EC. Ethical questions about screening. J Dev Behav Pediatr. 1998;19(5):350–352.

13. Garg A, Boynton-Jarrett R, Dworkin PH. Avoiding the unintended consequences of screening for social determinants of health. JAMA. 2016;316(8):813–814.

14. Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. Washington, DC: National Academy of Medicine; 2017. https://nam.edu/wp-content/uploads/2017/05/Standardized-Screening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf. Accessed March 8, 2018.

15. Gottlieb L, Tobey R, Cantor J, Hessler D, Adler NE. Integrating social and medical data to improve population health: opportunities and barriers. Health Aff (Millwood). 2016;35(11):2116–2123.

 
 

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