The Feasibility of Screening for Social Determinants of Health: Seven Lessons Learned

 

If addressing patients' social needs sounds overwhelming, the results of this pilot project might surprise you.

Fam Pract Manag. 2019 Sep-Oct;26(5):13-19.

Author disclosures: no relevant financial affiliations disclosed.

“Social determinants of health” (SDOH) has become an inescapable buzzword in family medicine in part because of the magnitude of impact that SDOH have on our patients' wellbeing. Drawing a direct comparison between social factors and medical conditions, researchers have estimated that low education, racial segregation, and low social support make a contribution to mortality that is equivalent to acute myocardial infarction, cerebrovascular disease, and lung cancer, respectively.1 Particularly as we strive toward the Quadruple Aim in health care, the “conditions in which people are born, grow, live, work, and age”2 can no longer be categorized strictly as nonmedical factors and, therefore, outside the scope of primary care.

Although many in primary care agree about the importance of screening patients for social needs and referring to supportive community resources, legitimate concerns exist about the feasibility of doing so. To explore these issues, our family medicine clinic recently conducted a nine-month SDOH pilot project. This article shares our outcomes and some surprising lessons learned.

KEY POINTS

  • Social factors such as low education, racial segregation, and low social support can have an effect on mortality that is similar to medical conditions such as acute myocardial infarction, cerebrovascular disease, and lung cancer.

  • In the authors' pilot study, 58 percent of clinicians began the project thinking they were too busy for social determinants of health (SDOH) screening, but only 21 percent felt that way by the end of the project.

  • Numerous SDOH screening tools exist, so practices can simply adapt one for their own use based on the social needs most common in their patient population.

REASONS TO CONSIDER SDOH SCREENING NOW

A variety of forces make this a promising time to integrate SDOH screening into routine medical practice. An early but growing body of evidence provides guidance on how to implement this practice in various settings.35 A number of tool-kits exist to support SDOH screening in clinical settings, including those from the American Academy of Family Physicians, American Academy of Pediatrics, and the National Association of Community Health Centers. Previous initiatives have demonstrated that screening for social needs in medical settings is acceptable to patients6 and can result in better access to community resources and resolution of social needs.7,8 Although studies measuring the effect of SDOH screening on health outcomes are limited, some investigators have found benefits related to anxiety,9 blood pressure, and low-density lipoprotein.10

SDOH screening is becoming more financially feasible as alternative payment models such as shared savings programs and global capitation provide a revenue stream to support a

ABOUT THE AUTHORS

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Dr. Bleacher is a faculty member at the University of Colorado Family Medicine Residency program and leads the community engagement committee at the AF Williams Family Medicine Center in Denver....

Dr. Lyon is the associate program director of the University of Colorado Family Medicine Residency Program and an associate vice chair of clinical affairs for the Department of Family Medicine.

Dr. Mims is a third-year resident and chief resident at the University of Colorado Family Medicine Residency.

Kathy Cebuhar is a practice transformation facilitator with the innovation program at University of Colorado.

Anowara Begum is a professional research assistant with the Department of Family Medicine and Internal Medicine at the University of Colorado-Denver. She coordinated the project activities and conducted surveys and interviews.

Author disclosures: no relevant financial affiliations disclosed.

References

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1. Galea S, Tracy M, Hoggatt KJ, DiMaggio C, Karpati A. Estimated deaths attributable to social factors in the United States. Am J Public Health. 2011;101(8):1456–1465....

2. World Health Organization. Social determinants of health. https://www.who.int/social_determinants/sdh_definition/en/. Accessed Aug. 13, 2019.

3. Cullen D, Woodford A, Fein J. Food for thought: a randomized trial of food insecurity screening in the emergency department. Acad Pediatr. 2019;19(6):646–651.

4. Gottlieb L, Hessler D, Long D, Amaya A, Adler N. A randomized trial on screening for social determinants of health: the iScreen study. Pediatrics. 2014;134(6):e1611–1618.

5. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial. JAMA Pediatr. 2016;170(11):e162521.

6. Hamity C, Jackson A, Peralta L, Bellows J. Perceptions and experience of patients, staff, and clinicians with social needs assessment. Perm J. 2018;2218–105.

7. Hassan A, Scherer EA, Pikcilingis A, et al. Improving social determinants of health: effectiveness of a web-based intervention. Am J Prev Med. 2015;49(6):822–831.

8. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296–304.

9. Grant C, Goodenough T, Harvey I, Hine C. A randomised controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector. BMJ. 2000;320(7232):419–423.

10. Berkowitz SA, Hulberg AC, Standish S, Reznor G, Atlas SJ. Addressing unmet basic resource needs as part of chronic cardiometabolic disease management. JAMA Intern Med. 2017;177(2):244–252.

11. Bachrach D, Pfister H, Wallis K, Lipson M. Addressing Patients' Social Needs: An Emerging Business Case for Provider Investment. New York, NY: The Commonwealth Fund; 2014.

12. Lovelace J. Integrating Health Care and Supported Housing to Improve the Health and Well-being of the Homeless: A Population Health Case Report. Washington, DC: National Academy of Medicine; 2016.

13. Manchanda R, Gottlieb L. Upstream Risks Screening Tool and Guide V2.6. Los Angeles, CA: HealthBegins; 2015.

14. De Jong Gierveld J, Van Tilburg T. A six-item scale for overall, emotional, and social loneliness: confirmatory tests on survey data. Res Aging. 2006;28(5):582–598.

15. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26–32.

16. Brcic V, Eberdt C, Kaczorowski J. Development of atool to identify poverty in a family practice setting: apilot study. Int J Family Med. 2011:epub812182.

17. Domestic abuse: how to ask. Stanford School of Medicine website. http://domesticabuse.stanford.edu/screening/how.html. Accessed Aug. 13, 2019.

18. Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23(5):561–566.

19. Wasson JH, Johnson DJ, Mackenzie T. The impact of primary care patients' pain and emotional problems on their confidence with self-management. J Ambul Care Manage. 2008;31(2):120–127.

 
 

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