Hospitals struggle to advance social determinants of health

The waiting rooms at OSF HealthCare’s clinics are pretty standard—magazines, TVs and chairs—except for one detail: iPads.

Patients who check in for primary-care appointments are encouraged to use the tablet to fill out a short 14-question survey that assesses their likelihood of facing challenges with 10 domains of social determinants of health, such as food, transportation or financial insecurity.

It’s not what many patients expect when waiting to see their primary-care doctor, particularly in rural Illinois, where many of OSF’s clinics are located.

But social determinants are as influential to a patient’s health as their vital signs, said Dr. Sarah Stewart de Ramirez, an emergency medicine physician and vice president for clinical innovation at OSF Innovation. That means they’re important to screen for—and the “cornerstone of any great screening strategy is to routinely offer it,” she said.

Results from the screening are delivered to the patient’s electronic health record. If a patient is identified as needing some type of social support—such as information about a local food pantry—a nurse or physician will offer to connect them to a care manager, as well as include information on relevant community-based organizations or hospital resources in the patient’s discharge instructions.

For now, that’s the bulk of the program, which is the challenge healthcare providers of all stripes face. While it’s one thing to know a patient is struggling with food insecurity, it’s another to actually address it—let alone track improvements over time.

OSF’s long-term vision is to create a tightly connected coordinated community care network that links healthcare providers and community groups—allowing them to more closely refer and send updates on patients to one another—but they’re still in the early stages of better identifying those who need help, Stewart de Ramirez said.

Screening for social determinants offers a “touch-point,” added Dr. Michael Petersen, social determinants of health and health innovation lead for Accenture’s health practice. “Then the question is: What do I do with this information?”

While still uncommon among hospitals, taking that first step—screening for social determinants of health—has been growing. It’s gotten easier as developers of EHR systems have added new screening modules, making it simpler for providers to assess patients’ social needs.

Those EHR modules are the primary way hospitals screen for social determinants, Petersen said.

Epic Systems Corp., the software provider behind OSF’s EHR, and Cerner Corp.—together accounting for more than half the EHR market among acute-care hospitals—both launched screening tools within their systems in 2018. OSF’s screening program was developed in-house.

For many health systems, the challenge to rolling out a program to identify patients struggling with social needs is figuring out the best way to screen for something that patients might not feel comfortable discussing—and then figuring out how to use it across their sites.

UnityPoint Health, a system based in Iowa, is in the process of rolling out a standardized way to screen patients for social determinants in its facilities across the Midwest, after a successful pilot in Waterloo, Iowa.

Providers during the pilot asked each patient entering an outpatient clinic: “Do you ever have difficulty making ends meet at the end of the month?” Based on the patient’s response, they possibly were screened more in-depth using a module within the EHR.

“We couldn’t spend the time, unfortunately, with every patient, at every encounter, going through a long questionnaire,” said Dr. Megan Romine, internist and medical director at UnityPoint Accountable Care. “We wanted to find a way to quickly identify which patients would benefit from that longer screening.”

In 2019, the pilot clinics in UnityPoint’s Waterloo region assessed more than 10,000 patients with the single-question screening, with 447 of them screened more in depth. Help with healthcare costs, transportation and access to medications were the top needs identified among those patients.

For UnityPoint, like OSF, standardized screening is just the first in a series of actions it plans to take to address social determinants.

Down the line, Romine said a goal is to automatically connect patients to appropriate community or in-house resources, as well as study how those connections affect emergency department visits, medication compliance and appointment no-show rates. “There’s really three steps, and that first one is identification,” she said.

In 2019, 40% of U.S. primary-care physicians said they frequently coordinate with social service agencies or other community providers, according to a recent survey conducted by researchers at the Commonwealth Fund and published in Health Affairs.

That’s a hefty amount. But not all of those physicians are operating within a formal, standardized program implemented at the organizational level.

“There’s a greater recognition that the medical providers really need to work in partnership” with social service providers, said Dr. Eric Schneider, senior vice president for policy and research at the Commonwealth Fund and co-author on the Health Affairs study. But there are challenges. Thirty-one percent of U.S. primary-care docs said the lack of a referral system was a major challenge to coordinating care.

The lead challenge cited by U.S. primary-care physicians—at 37%—was lack of follow-up from social service providers about what assistance the patient received.

That’s not surprising. While there’s some emerging technology designed to connect patients to social service programs, many hospitals still rely on social workers to know what organizations to call and to add that information to a patient’s discharge instructions, Petersen said. And there are few processes in place to ensure the patient followed through with the referral to get what they need.

Hospitals are increasingly trying to find ways to track the process more consistently, but that’s “where they’re having huge challenges,” Petersen said.

Some hospitals are finding innovative ways to address the problem through technology. ProMedica last year invested in Socially Determined, an analytics startup focused on social determinants. The Toledo, Ohio, system is collaborating with the startup on an initiative to link socio-economic information with health outcomes, in an effort to help track progress of referrals clinicians make to social service providers as well as the effectiveness of the system’s interventions.

Another health system, UMass Memorial Health Care, began using software from a company called Aunt Bertha in 2017, after consulting with social service programs.

In the past, UMass Memorial had relied on caregivers with “very deep expertise” to know the right program for a patient, said Christine Cernak, the system’s senior director of longitudinal care. But to really address social determinants, the health system realized it needed a more formal program.

With the new system, a caregiver can search for social service programs by ZIP code. Social workers and care coordinators can also track referral activity for some patients, since select social service providers can share confirmation after a patient has fulfilled their referral.

But that’s contingent on the social service program using Aunt Bertha’s software, too. And unlike hospitals—where more than 90% report being live on an EHR—community groups use disparate types of software to manage their cases, if they use any at all.

Aunt Bertha is part of an emerging segment of startups—including NowPow, Pieces Technologies and Unite Us—that are specifically designed to make it easier for hospitals to search for and connect with social service programs. Many of these startups integrate with the major EHR systems and offer the opportunity for electronic referrals to connected social service groups—but there’s no standard for interacting with social service providers.

New software platforms are “crucial to tracking the long-term outcomes of the patients, but it needs to be something that works for every organization, clinical or nonclinical,” said Stewart de Ramirez from OSF, which recently kicked off a pilot with a digital referral and case management software provider at its sites in Streator, Ill. She declined to share the name of the technology, since OSF is still evaluating which tools it plans to use systemwide.

So while a software system that allows providers to electronically refer patients to community groups sounds promising, it needs to be able to get that data to the right social service program—in practice, not just in theory. UMass Memorial is still working on overcoming that challenge.

Not everyone in UMass Memorial’s community has opted to use Aunt Bertha’s software, as most of the community-based organizations already had their own established processes for enrollment and coordination. “Change is hard to make,” Cernak said.

To get a critical mass of social service programs on systems interoperable with EHRs, it will arguably take a central group to push for it—and software providers are betting on hospitals taking up that mantle.

Some hospitals are stepping up. When Parkview Medical Center in Pueblo, Colo., decided to go live on a digital referral system from Pieces Technologies a year ago, it also purchased 10 licenses for the company’s case management system. It extended that software to local social service providers it expects to work with frequently—for free—as part of an effort to build up its network of collaborators, said Kelea Nardini, Parkview’s assistant vice president of quality and post-acute care.

Having a referral directory with social service providers they know are connected to the Pieces system has helped nurses and social workers in Parkview’s case management department feel more confident when screening patients for social needs, Nardini said. Before, “they would be hesitant to identify these needs, because they felt like they didn’t have any resources to be able to send them to,” she added. About 750 patients have been referred to outside groups through the software in the past year.

Henry Ford Health System in Detroit also decided to provide software to the community when launching Henry’s Groceries for Health, a pilot project to tackle food insecurity.

The pilot involved partnering with local food pantry Gleaners Community Food Bank, which delivered food to each enrolled patient every other week for a year. From November 2017 to May 2019, deliveries were made to roughly 300 patients who had multiple chronic conditions and screened positive for food insecurity.

But for the pilot, Henry Ford didn’t just give patients a referral—they enrolled patients directly in the delivery program with the food bank, which meant they needed to provide Gleaners with names, addresses and food preferences. That still counts as protected health information, according to Susan Hawkins, the system’s senior vice president of population health.

So to notify Gleaners of patients enrolled in the pilot, Henry Ford used a secure web application called REDCap, which is often used to build databases for clinical research. Henry Ford provided that application—which was updated regularly, as population health coordinators followed up with patients to hone their grocery preferences—to Gleaners for free.

It included the patients’ names and addresses, but no clinical information. “We just kept it to the bare minimum,” Hawkins said.