Multiple studies have demonstrated that health outcomes are caused or exacerbated by social, behavioral and economic risk factors. While health disparities are unfortunately not new, the pandemic has highlighted the prevalence of food and housing insecurity, exposure to discrimination or violence, and limited access to transportation and other services.
Hospitals and health systems are beginning to address these issues, but much remains to be done. The problem is complex. Providing equitable care starts with screening for social determinants of health. Yet there are limited screening resources specific to tertiary settings with no agreed-upon industry standard for measuring validity or success.
This explains why less than one-quarter of hospitals (24%) reported screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence—the key social needs associated with health outcomes, according to Fraze et al. (2019) in "Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals." The COVID-19 pandemic has clearly illustrated alarming health disparities affecting racial minorities and others across the nation and this will likely lead to more active interest in addressing key social needs by hospitals. Thus, feasible and effective screening methods are needed to propel this important element of care forward.
Increased screening is not only an equity and justice issue. There is value for healthcare organizations in early assessment of patient risk factors. As the study authors note, "The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform."
Here are three recommendations that can help hospitals to get started:
Define scope in a way that is feasible and aligned with organizational goals. Analyze data and systems to identify a feasible area to test screening within your organization. Pinpoint areas of highest need for your patient population and look at the policies, workflows and processes already in place. This allows organizations to prioritize what could make the most immediate impact without completely overhauling systems and processes. At Virginia Mason Medical Center, for example, we used SDOH risk screening to address delays in hospital discharges and improve post-discharge care for homeless patients by placing them in respite care programs.
Pick a tool and screen all patients. Review existing screening tools, then choose one appropriate for your hospital system and the demographics of the care setting. (Examples of tool kits to support SDOH screening in clinical settings are available from the American Academy of Family Physicians and the National Association of Community Health Centers.) Screening questions should guide your staff to better understand the patient's ability to afford medications, food and housing. Social risk screening should also be actionable. Start with a small number of social domains to concentrate your efforts related to these areas of focus. Patients who self-report SDOH information show improved disclosure, particularly for new patients and those without an established provider relationship, while also taking the burden of screening off providers.
Optimize existing interventions. Hospitals already provide referrals to social services, but this often occurs later in the patient's journey. Discuss barriers with your staff and make it a priority to intervene earlier in the patient's care continuum. Educational preparation will help your teams understand how SDOH can lead to unnecessary emergency department visits, readmissions, and rising healthcare costs. Ensure that social services' information and referral tool kits are available to all appropriate staff members, including care coordinators and patient navigators. Simple interventions will allow the team to take small steps that may make a large impact. Assess programs regularly to refine tool kits, identify gaps, and continue to tailor appropriate care. As your team gains insight into the challenges that patients face and feels empowered with resources and information, they will be more willing and better prepared to engage in SDOH screening.
Healthcare professionals should strive to make patient-centered care and health equity the standard. Screening for the social determinants of health enables us to better understand our patients' life experiences and, ultimately, help them lead healthier lives.
