Social determinants of health (SDOH) -- defined by the AAFP as the conditions under which people are born, grow, live work and age -- have become a topic of great interest nationwide as physicians, health policymakers and others seek ways to keep people healthier.
In fact, a policy statement adopted by the AAFP Board of Directors in April asserts that "physicians need to know how to identify and address SDOH to be successful in promoting positive health outcomes for individuals and populations."
And now, new research published in the September/October Annals of Family Medicine adds to the national knowledge base already under construction.
In an article titled "Adoption of Social Determinants of Health EHR Tools by Community Health Centers,"(www.annfammed.org) researchers highlight the results of a pilot study conducted in three Pacific Northwest community health centers in which tools based on electronic health records (EHRs) were utilized to collect, review and act on patient-reported SDOH data.
Researchers were most interested in describing and evaluating how clinics adopted the EHR SDOH screening tools into their normal workflow. Authors also identified barriers and facilitators to adopting the screening tools and assessed how clinics used the EHR tools to document SDOH needs in patient records.
- New research published in Annals of Family Medicine analyzes adoption of an electronic health record (EHR)-based tool for documenting patients' social determinants of health (SDOH) in three community health centers.
- Researchers noted a growing national emphasis on EHR documentation of SDOH screening and referral, but said there are no evidence-based guidelines on how to do so.
- Findings revealed that nearly all patients screened had at least one SDOH need documented in the EHR, but many refused clinic assistance in addressing those needs.
Corresponding author Rachel Gold, Ph.D., M.P.H., is an investigator at the Kaiser Permanente Northwest Center for Health Research in Portland, Ore., and the lead research scientist at OCHIN Inc. (formerly the Oregon Community Health Information Network), also in Portland.
In an interview with AAFP News, Gold noted the timeliness of the research.
"There is a rapidly growing national emphasis on EHR-documented social determinants of health screening and referral-making, but there is also very little empirical evidence to guide care providers on how to implement such activities.
"Social determinants of health screening will not be easy for many care settings to implement, so it is essential to study how it can be done effectively to inform others seeking to do this important work," said Gold.
Late in 2015, researchers recruited three community health center clinics whose patient populations were primarily uninsured or enrolled in public insurance. Clinic staff attended training sessions and were provided written materials explaining SDOH and the SDOH tools that had been developed for the study.
The SDOH domains included in the EHR tool were education level, financial resource strain, housing insecurity, food insecurity, exposure to violence, physical inactivity, social isolation and stress. The EHR tool also let clinics add other SDOH domains -- for instance, alcohol use, depression or education -- or choose multi-domain screening tools.
The SDOH data tools were activated in June 2016 and researchers followed study clinics until July 2017.
Social determinants data were collected on 1,130 patients, and of those
- 97 percent to 99 percent had an SDOH need documented in the EHR, and
- 19 percent received an EHR-documented SDOH referral.
After the pilot was underway, researchers added, at the clinics' request, questions asking patients if they wanted help with SDOH needs. In the three months following that addition,
- clinic A screened 62 patients with more than one SDOH, of whom just 15 percent requested help; and
- clinic B screened 178 patients with more than one SDOH, of whom just 21 percent wanted help.
"We were surprised at how few patients desired clinic assistance in addressing reported SDOH needs," said Gold. "We need to conduct more research to understand why patients decline assistance."
Researchers learned that having a clinic champion who was EHR-savvy was helpful in supporting adoption of EHR tools.
Barriers included staff perceptions that EHR-based SDOH tools added a layer of difficulty in collecting and acting on SDOH data, and required an extra step of data entry when the information was collected on paper.
The authors also noted that until the follow-up questions about patients' desire for help were added, "the high positive screening rate yielded an unmanageable follow-up workload."
The researchers reported that when adopting EHR SDOH tools, clinics should consider how to integrate such tools into existing workflow processes, ensure that staff tasked with SDOH efforts receive adequate tool training and access, and consider that timing of data entry impacts how and when SDOH data can be used.
Family Physician Perspective
Family physician Peter Mahr, M.D., of Portland, Ore., was one of several coauthors. Since 2002, Mahr has practiced medicine at the Multnomah County Health Department, which operates a network of federally qualified health clinics.
As medical director of the Southeast Health Center clinic, Mahr told AAFP News he understands all too well how social determinants affect a patient's health.
"Family physicians see patients in the context of their family, community and environment. We care for a multitude of chronic medical problems like diabetes, hypertension, alcoholism and mood disorders, which are all directly or indirectly affected by social determinants of health," said Mahr.
"Social determinants can shape the course of a disease; consider, for example, a child affected by exposure to violence and trauma who then develops drug dependency as an adult."
SDOH also affect treatment and outcomes, said Mahr. "Patients struggling to buy food often can't afford medications, and patients without adequate housing will face repeated admissions to the hospital for congestive heart failure and other issues," he added.
He drove the point home with a real and very recent story.
"I just saw a middle-aged man today as a new patient. He had diabetes and hypertension and had become homeless due to job loss. His alcoholism, diabetes and high blood pressure were uncontrolled," said Mahr.
"Fortunately, he had accessed community resources to help him stop drinking and was able to establish care with me; we will be able to help him regain control of his chronic medical conditions. But his story shows how patients are just one or two steps away from medical disaster due to socioeconomic forces in their lives."
Family physicians, with their focus on the whole patient, serve front and center in this battle. And the extent to which social factors affect patients -- based on percentages detailed in the study -- was surprising even to Mahr.
"Huge numbers of our patients struggle with the necessities of life -- like food and housing -- which makes taking care of their personal health all that more difficult," he said.
He welcomed the study findings that show it is possible to begin gathering data about patients' SDOH and then address them -- to some extent -- during clinic visits.
Furthermore, Mahr said he hopes family physicians feel empowered "to take an active role in advocating for changes in public policy that will improve social determinants of health for our patients and communities."
Further Author Discussion
Lead author Gold said her interest in SDOH was driven by the fact that social determinants are a "leading cause of persistent health disparities and drive health outcomes more powerfully than does clinical care."
Gold said the high rates of reported SDOH need "underscore the importance of screening," and added, "it is essential to ask patients with reported social determinants of health needs if they want clinic assistance in addressing those needs.
"This study shows that it is feasible for clinics to adopt systematic, EHR-documented social determinants of health screening/referral-making, but they are likely to encounter barriers in their adoption process," said Gold. Clinics likely will need resources and support.
Gold noted that the research team is now conducting a larger-scale study on how to provide such support with the AAFP's new Neighborhood Navigator as a resource for the current study's clinics.
"An emerging body of evidence indicates that systematic screening for social determinants of health increases rates of referral to social services and can lead to improved health outcomes," said Gold. Therefore, EHR documentation of patients' needs could help care teams understand potential impacts on their patients' health and ability to act on care recommendations.
Care plans could then be adjusted accordingly -- for instance, by prescribing non-refrigerated medications for a patient who is homeless.
Lastly, Gold stressed that much more research is needed. "National leaders are asking health care providers to document social determinants of health without evidence-based guidance on how best to do so. These findings will help build that evidence base," she said.
Related AAFP News Coverage