Healthcare providers are struggling to get patients to tell them about problems they face outside of the exam room.
Providers want patients to tell them about their social needs but confront mistrust, shame and other obstacles to people sharing unflattering details about their personal lives, said Lauren Barca, vice president of quality at 86Borders, a patient engagement vendor. Patients also may not trust what providers will do with the information they collect, she said.
For example, parents screened about housing or food security may feel shame or worry about the potential consequences of revealing that their living situations are precarious or that they don't always have enough for their children to eat. They may fear being reported to government authorities if they reveal troubles at home.
"The problem is, we're asking: 'How hungry are your children on a scale of one to 10?’” Barca said. "I would not want to answer that because I'm suspicious. What are you going to use the data for? Are you going to notify child protective services? Are you going to send someone to my house?"
Moreover, some patients are pessimistic about these kinds of interventions and don't see an upside to disclosing non-medical issues because they don't believe it will lead to assistance. Without referral systems and robust social services, providers have historically been unable to help patients confront these challenges.
A recent push from regulators has intensified efforts to screen patients for social determinants of health. Still, many providers are grappling with low levels of response and inaccurate data. The result is an opaque view of factors that affect health and an inability to resolve problems, Barca said.
In 2020, nearly 63% of Oakland, California-based Kaiser Permanente patients screened positive for problems such as food, housing and income insecurity. Last year, the share was 68%, according to Dr. Anand Shah, vice president of social health. The nonprofit integrated health system is not always able to refer patients to needed services because resources vary by location, he said.
Providers must confront distrust among patients and promote interventions to optimize screening and referral systems, Barca said. Better communications between health systems, care teams and patients and being more empathetic are simple but essential steps, she said.
"These are questions that are incredibly vulnerable, and they have to be asked in a way that is sensitive if we're expecting honest answers back in a trusted relationship," Barca said.
Kaiser Permanente and Durham, North Carolina-based Duke Health are expanding screening efforts via technology and integrating social needs questions with clinical workflows to increase uptake. They are also tailoring language to specific patient populations and utilizing outreach workers to improve engagement and accuracy.
The work aims to establish trust and grow awareness among patients that health systems can connect them to support, said Lisa McNerney, who manages clinical social workers for Duke Health.
But that only goes so far. Despite operating centralized systems for social care referrals, these health systems face shortages of community-based resources—particularly in rural areas—for housing and food insecurity, behavioral health, and financial assistance.
Increasing response and accuracy
The push for social needs screening has come in large part from federal and state regulators. The Centers for Medicare and Medicaid Services has emphasized screening efforts in value-based arrangements and has developed financial incentives that induce providers to invest in infrastructure that advances social health. Model questionnaires from trade organizations, accreditors and CMS also have accelerated screening efforts, researchers from the Medical College of Wisconsin, the University of Georgia and Johns Hopkins University reported in a study published in the journal Health Equity last year.
Health systems intend to use the information to customize treatment plans and reduce costs by preventing poor health outcomes. Yet many are still determining the optimal setting and format for screenings and how to phrase deeply personal questions.
Kaiser Permanente aims to screen 3 million members this year by broadening its outreach strategy to include in-person visits and online, telephone, and text support. The health system is asking patients about access to food, housing, financial assistance and transportation.
Most of their screenings are completed through technology, such as pre-visit forms and calls from care navigators, Shah said. Kaiser Permanente also uses iPads to screen patients in clinical settings. The questions are tailored to specific conditions and patient populations, he said.
Even with a comprehensive screening system, healthcare organizations must confront the reasons a patient may not be forthcoming, Barca said. To do this, providers are being more transparent about why they are quizzing patients and creating scripts that clinicians and outreach workers use to communicate the purpose of social needs screenings.
Kaiser Permanente drafted questions in multiple languages and tested them for engagement among patients. The screenings include explanations about why the information is relevant to clinical care. That helps patients understand how their responses will be used, which has increased uptake, Shah said.
“We emphasize that we care about your health and well-being, your social well-being is part of your overall health and that these are common issues that are faced by many other people and that you are not alone,” Shah said.
Like Kaiser Permanente, Duke Health uses scripts and trains caregivers to encourage open dialogues with patients, McNerney said.
“Oftentimes, families don't want to admit to their providers when they're struggling. And so really providing the providers with some some language and some ways that they can talk with their patients to help them feel a little bit more comfortable in disclosing that they're struggling goes a long way,” McNerney said.
When providers identify patients with health-related social needs, they must be able to seamlessly refer them to resources, McNerney said. Duke Health has integrated a North Carolina Department of Health and Human Services social services hub with its electronic health record system. This enables the health system to direct patients to community resources and track whether they found what they needed, she said.
Implementing social interventions
Duke Health increased screening in 2020 after North Carolina partnered with the technology firm Unite Us to establish NCCARE360, an online platform that allows providers to refer patients to community-based resources. Using the tool, Duke screened nearly 8,500 patients per month last year, according to a report published in the New England Journal of Medicine in April.
Kaiser Permanente recently developed a hub that directs patients to support mechanisms such as websites, call centers and government programs. The health system employs a mix of care navigators, community health workers and call center agents trained in trauma-informed care for outreach and support, Shah said.
The effectiveness of these interventions, however, is constrained by scarce resources, McNerney said. In North Carolina, more patients are reporting food insecurity, partially driven by inflation. But getting assistance from an overtaxed safety net is challenging, especially for people with behavioral health needs, she said.
"Resources are fairly limited," McNerney said. "When you look at how many people actually screened positive for challenges with health-related social needs versus the amount of resources available in the community, there is a large gap."