Implementing screening for social determinants of health using the Core 5 screening tool

Integrating Social Needs into Health Care: An Implementation Science Perspective

Unmet social needs (e.g., housing instability, food insecurity, transportation barriers) impact a patient's ability to participate in health-seeking behaviors (e.g., physical activity, routine preventive care) and to achieve optimal health. A rapidly growing number of health care systems are incorporating social needs screening and assistance into clinical workflows, yet many implementation and sustainability challenges exist and require collaboration with social service organizations. This review highlights implementation approaches used within this rapidly changing US landscape and uses implementation science frameworks to systematically identify multilevel barriers to and facilitators of implementing and sustaining social needs care. Policies and economic investments are necessary as they determine critical barriers and facilitators within the clinical and social service contexts. Implementation may be further strengthened by cross-sector engagement, evidence-based implementation strategies, and capacity building within clinical and social service organizations. Successful, sustained implementation of social needs care may improve the quality of health care, population health, and health equity.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

DalSpace dalspace.library.dal.ca/handle/10222/80835.

Screening tools to address social determinants of health in the United States: A systematic review

The Centers for Medicare & Medicaid Services have mandated that hospitals implement measures to screen social determinants of health (SDoH). We sought to report on available SDoH screening tools. PubMed, Scopus, Web of Science, as well as the grey literature were searched (1980 to November 2023). The included studies were US-based, written in English, and examined a screening tool to assess SDoH. Thirty studies were included in the analytic cohort. The number of questions in any given SDoH assessment tool varied considerably and ranged from 5 to 50 (mean: 16.6). A total of 19 SDoH domains were examined. Housing (n = 23, 92%) and safety/violence (n = 21, 84%) were the domains assessed most frequently. Food/nutrition (n = 17, 68%), income/financial (n = 16, 64%), transportation (n = 15, 60%), family/social support (n = 14, 56%), utilities (n = 13, 52%), and education/literacy (n = 13, 52%) were also commonly included domains in most screening tools. Eighteen studies proposed specific interventions to address SDoH. SDoH screening tools are critical to identify various social needs and vulnerabilities to help develop interventions to address patient needs. Moreover, there is marked heterogeneity of SDoH screening tools, as well as the significant variability in the SDoH domains assessed by currently available screening tools.

Utilizing a Tailored Approach to Standardized Screening of Health-Related Social Needs

BACKGROUND

Despite the increased awareness of social determinants of health (SDoH), integrating social needs screening into health care practice has not consistently occurred.

LOCAL PROBLEM

No social needs screening using recommended standardized questions was available at an outpatient hemodialysis clinic.

METHODS

Plan-Do-Study-Act cycles, based on the Model for Improvement, were used to implement the Core 5 SDoH screening tool, a staff referral process, and an evaluation of the implementation process.

INTERVENTION

A standardized social needs screening tool and a staff referral process were implemented. An evaluation of the implementation process also occurred.

RESULTS

Of 73 patients screened, 21 reported 32 unmet social needs; all received referrals to community resources. Nurses demonstrated high acceptance and usability of the tool and the referral process.

CONCLUSIONS

Implementing a standardized screening and referral process customized to clinical workflow enhanced the identification of social needs in patients undergoing hemodialysis.

Surgeon Understanding and Perceptions of Social Determinants of Health

INTRODUCTION

Social determinants of health impact surgical outcomes. Characterization of surgeon understanding of social determinants of health is necessary prior to implementation of interventions to address patient needs. The study objective was to explore understanding, perceived importance, and practices regarding social determinants of health among surgeons.

METHODS

Surgical residents and attending surgeons at a single academic medical center completed surveys regarding social determinants of health. We conducted semi-structured interviews to further explore understanding and perceived importance. A conceptual framework from the World Health Organization (WHO) Commission on Social Determinants of Health informed the thematic analysis.

RESULTS

Survey response rate was 47.9% (n = 69, 44 residents [63.8%], 25 attendings [36.2%]). Respondents primarily reported good (n = 29, 42.0%) understanding of social determinants of health and perceived this understanding to be very important (n = 42, 60.9%). Documentation occurred seldom (n = 35, 50.7%), and referrals occurred seldom (n = 26, 37.7%) or never (n = 20, 29.0%). Residents reported a higher rate of prior training than attendings (95.5% versus 56.0%, P < 0.001). Ten interviews were conducted (six residents, four attendings). Residents demonstrated greater understanding of socioeconomic positions and hierarchies shaped by structural mechanisms than attendings. Both residents and attendings demonstrated understanding of intermediary determinants of health status and linked social determinants to impacting patients' health and well-being. Specific knowledge gaps were identified regarding underlying structural mechanisms including the social, economic, and political context that influence an individual's socioeconomic position.

CONCLUSIONS

Self-reported understanding and importance of social determinants of health among surgeons were high. Interviews revealed gaps in understanding that may contribute to limited practices.

MS care: integrating advanced therapies and holistic management

Lifestyle and environmental factors are key determinants in disease causality and progression in neurological conditions, including multiple sclerosis (MS). Lack of exercise, poor diet, tobacco smoking, excessive alcohol intake, social determinants of health, concomitant medications, poor sleep and comorbidities can exacerbate MS pathological processes by impacting brain health and depleting neurological reserves, resulting in more rapid disease worsening. In addition to using disease-modifying therapies to alter the disease course, therapeutic strategies in MS should aim to preserve as much neurological reserve as possible by promoting the adoption of a "brain-healthy" and "metabolically-healthy" lifestyle. Here, we recommend self-regulated lifestyle modifications that have the potential to improve brain health, directly impact on disease progression and improve outcomes in people with MS. We emphasise the importance of self-management and adopting a multidisciplinary, collaborative and person-centred approach to care that encompasses the healthcare team, family members and community support groups.

Linking Adverse Childhood Experiences and Other Risk Factors to Subjective Cognitive Decline in an Aging Population

Introduction

The Centers for Disease Control and Prevention's Healthy Brain Initiative (HBI) encourages an interdisciplinary approach to addressing the burden of subjective cognitive decline (SCD) among the aging US population as that population continues to increase. Our study is one of the first to evaluate associations between SCD and adverse childhood experiences (ACEs) and other modifiable risk factors to support implementation of the initiative.

Methods

We used multivariate logistic regression to assess data from the 2020 Behavioral Risk Factor Surveillance System survey to evaluate associations between SCD and ACEs scores and sociodemographic, behavioral, and clinical risk factors. Models were weighted to account for the complex survey design.

Results

Approximately 8.1% of survey respondents reported experiencing SCD within the past 12 months. Adjusted regression analysis showed that conditions such as depression (AOR, 2.85; 95% CI, 2.29-3.55), arthritis (AOR, 1.30; 95% CI, 1.05-1.60), and diabetes (AOR, 1.33; 95% CI, 1.05-1.68) were significantly associated with SCD. SCD was also associated with experiencing more than 3 falls per year (AOR, 2.95; 95% CI, 2.13-4.09), sleeping more than 9 hours per night (AOR, 2.06; 95% CI, 1.37-3.09), and physical inactivity (AOR, 1.32; 95% CI, 1.03-1.68). Two or more ACEs also significantly increased the odds of SCD (AOR, 1.69; 95% CI, 1.36-2.10).

Conclusion

Findings from our study can be used to inform policy, environment, and systems change efforts aimed at addressing modifiable risk factors to support healthy aging. The role of ACEs as determinants of brain health across the life course should also be considered in the design of clinical and community-based interventions.

The heart of it all: Body dysmorphic disorder in cosmetic surgery

BACKGROUND

Body Dysmorphic Disorder (BDD) represents a prevalent mental health condition characterized by distress arising from self-perceived physical imperfections. BDD serves as a contraindication to aesthetic surgery. Recognizing BDD holds paramount importance for plastic surgeons, as it is instrumental in averting the exacerbation of this condition while ensuring appropriate referrals.

OBJECTIVE

This study aimed to investigate the prevalence of BDD in cosmetic surgery patients and to pinpoint key characteristics associated with BDD. This information provides plastic surgeons with specific factors to consider during preoperative evaluations.

METHODS

We employed TriNetX database to identify patients with BDD who underwent cosmetic surgery identified by Current Procedural Terminology codes. Demographics and patient characteristics were identified using the International Classification of Diseases 10 codes. We calculated odds ratios (OR) by using chi-squared tests to assess risk factors among patients with BDD.

RESULTS

Of 226,374 patients who underwent plastic surgery between August 2002 and August 2022, fewer than 0.1% were diagnosed with BDD. Of the BDD patients, 52.1% were diagnosed after cosmetic surgery. Compared with the control group, BDD patients were more likely to undergo rhinoplasty (OR=1.784, p = 0.004) and nonlocalized lipectomy (OR=1.448, p = 0.021) and less likely to undergo blepharoplasty (OR=0.451, p = 0.002). Findings indicated a strong association between BDD patients undergoing cosmetic procedures and comorbid psychiatric conditions such as depression (OR=4.279, p < 0.05), anxiety (OR=5.490, p < 0.05), and Attention-Deficit Hyperactivity Disorder (OR=3.993, p < 0.05).

CONCLUSIONS

These findings underscore the ongoing significance of BDD in the context of cosmetic surgery, potentially indicating a lower surgery rate among BDD patients compared with previous estimates. Nevertheless, avenues for further improvement persist. Our data affirm the noteworthy occurrence of postsurgery BDD development, thereby highlighting the ongoing necessity for psychiatric evaluation in surgical patients.

Increasing Social Determinants of Health Screening Rates Among Six Endocrinology Centers Across the United States: Results From the T1D Exchange Quality Improvement Collaborative

Social determinants of health (SDOH) are strongly associated with outcomes for people with type 1 diabetes. Six centers in the T1D Exchange Quality Improvement Collaborative applied quality improvement principles to design iterative Plan-Do-Study-Act cycles to develop and expand interventions to improve SDOH screening rates. The interventions tested include staff training, a social risk index, an electronic health record patient-facing portal, partnerships with community organizations, and referrals to community resources. All centers were successful in improving SDOH screening rates, with individual site improvements ranging from 41 to 70% and overall screening across the six centers increasing from a baseline of 1% to 70% in 27 months.

A Health System Framework for Addressing Structural Racism: Mass General Brigham's United Against Racism Initiative

The legacy of racism and structural inequality has taken a heavy toll on the health care system and the health outcomes of patients and members of community catchment areas. To achieve optimal health outcomes for all, health systems will need to enact structural change that is meaningful, measurable, and rooted in evidence. We describe an antiracism campaign organized into three pillars of focus (Leadership/Employees/Culture, Patient Care Equity, and Community Health and Policy Advocacy) and implemented across Mass General Brigham, a large integrated health system in the northeast of the United States. Our study ranges from the foundational to the aspirational and examples of data-driven areas of focus, programs (e.g., staff education, social risk mitigation, and new models of clinical service), and metrics developed for the health care workforce, patients, and surrounding communities are presented.

Cashin A, Barker T, A. Boyd M, Chiarotto A, Dewidar O, Petkovic J, Sharma S, Tugwell P, Moseley GL. The 'what' and 'how' of screening for social needs in healthcare settings: a scoping review

Background

Adverse social determinants of health give rise to individual-level social needs that have the potential to negatively impact health. Screening patients to identify unmet social needs is becoming more widespread. A review of the content of currently available screening tools is warranted. The aim of this scoping review was to determine what social needs categories are included in published Social Needs Screening Tools that have been developed for use in primary care settings, and how these social needs are screened.

Methods

We pre-registered the study on the Open Science Framework (https://osf.io/dqan2/). We searched MEDLINE and Embase from 01/01/2010 to 3/05/2022 to identify eligible studies reporting tools designed for use in primary healthcare settings. Two reviewers independently screened studies, a single reviewer extracted data. We summarised the characteristics of included studies descriptively and calculated the number of studies that collected data relevant to specific social needs categories. We identified sub-categories to classify the types of questions relevant to each of the main categories.

Results

We identified 420 unique citations, and 27 were included. Nine additional studies were retrieved by searching for tools that were used or referred to in excluded studies. Questions relating to food insecurity and the physical environment in which a person lives were the most frequently included items (92-94% of tools), followed by questions relating to economic stability and aspects of social and community context (81%). Seventy-five percent of the screening tools included items that evaluated five or more social needs categories (mean 6.5; standard deviation 1.75). One study reported that the tool had been 'validated'; 16 reported 'partial' validation; 12 reported that the tool was 'not validated' and seven studies did not report validation processes or outcomes.

Characterizing the relative frequency of clinician engagement with structured social determinants of health data

OBJECTIVE

Electronic health records (EHRs) are increasingly used to capture social determinants of health (SDH) data, though there are few published studies of clinicians' engagement with captured data and whether engagement influences health and healthcare utilization. We compared the relative frequency of clinician engagement with discrete SDH data to the frequency of engagement with other common types of medical history information using data from inpatient hospitalizations.

MATERIALS AND METHODS

We created measures of data engagement capturing instances of data documentation (data added/updated) or review (review of data that were previously documented) during a hospitalization. We applied these measures to four domains of EHR data, (medical, family, behavioral, and SDH) and explored associations between data engagement and hospital readmission risk.

RESULTS

SDH data engagement was associated with lower readmission risk. Yet, there were lower levels of SDH data engagement (8.37% of hospitalizations) than medical (12.48%), behavioral (17.77%), and family (14.42%) history data engagement. In hospitalizations where data were available from prior hospitalizations/outpatient encounters, a larger proportion of hospitalizations had SDH data engagement than other domains (72.60%).

DISCUSSION

The goal of SDH data collection is to drive interventions to reduce social risk. Data on when and how clinical teams engage with SDH data should be used to inform informatics initiatives to address health and healthcare disparities.

CONCLUSION

Overall levels of SDH data engagement were lower than those of common medical, behavioral, and family history data, suggesting opportunities to enhance clinician SDH data engagement to support social services referrals and quality measurement efforts.

social determinants of health in multiple sclerosis

Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants — that is, the ‘risks of risks’ — on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed.

Here, the authors discuss the potential effects of social determinants of health on multiple sclerosis risk and outcomes. They suggest that addressing these determinants of health could substantially improve the lives of individuals with multiple sclerosis and call for more research.

Addressing an individual’s social determinants of health — that is, the conditions under which they are born, grow, live, work and age — could provide opportunities to reduce the burden of living with multiple sclerosis (MS).

Individual factors that may influence MS-related outcomes include sex, gender and sexuality, race and ethnicity, education and employment, socioeconomic status, and domestic abuse.

Societal infrastructures, including access to food, health care and social support, can also affect MS-related outcomes.

Awareness of the specific circumstances of a patient with MS might help neurologists deliver better care.

Social determinants of health are not static and can change according to wider sociopolitical contexts, as highlighted by the COVID-19 pandemic.

Rigorous studies of interventions to ameliorate the effects of poor social determinants on people with MS are urgently needed.

Social Determinants of Health: What Are They and How Do We Screen

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report recognizes nurses' impact on the medical and social factors that drive health outcomes (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021). The report calls for nursing to take bold steps to address individual and structural level social determinants of health (SDoH)-or social and environmental factors contributing to poor health, poor health outcomes, and health disparities (NASEM, 2021, p. 5). Nurses must recognize the significance of SDoH on patient health outcomes in order to advance health equity and employ nursing interventions to affect positive change for our patients. SDoH are part of our patients' stories, and holistic nursing means we know the whole patient story. Although it is now widely recognized that SDoH affect health outcomes, a key challenge for nurses is that they represent an enormous range of factors-from food and housing insecurity to personal safety and environmental exposures-that may be more or less able to change with interventions in clinical settings. Furthermore, concerns have been raised that screening for SDoH-especially when not done with sensitivity, cultural competence, or ready intervention-may compromise therapeutic relationships and marginalize patients (Wallace et al., 2020). However, despite these concerns, healthcare systems are widely adopting SDoH assessments, generally through electronic health record screening questions, and attempting to implement associated workflows and interventions. Given this landscape, the purpose of this article, within this special issue of Orthopaedic Nursing, is to provide an overview of SDoH factors, identify best practices related to screening and referral, and highlight nurse-directed interventions in clinical settings.

A qualitative analysis of perceptions of and reactions to COVID-19

OBJECTIVE

To understand communities' perceptions, beliefs, and health-related behavior choices related to COVID-19 in order to guide public health nursing communication and interaction with patients and the community.

DESIGN

A qualitative study, guided by the Health Belief Model (HBM), strove to comprehend the perceptions and reactions to COVID-19 among Wisconsinites.

SAMPLE

Twenty-five diverse Wisconsin residents aged 18 or older.

MEASUREMENTS

Semi-structured interviews provided information about individuals' attitudes, perceptions, and reactions to COVID-19. Interviews were audio-recorded, transcribed, and thematic analysis was conducted to identify themes.

RESULTS

We identified three major themes: (1) "health care starts way before you ever enter the doors of a healthcare facility"; (2) "to live in a society is to help each other"; and (3) mental health as impacted by COVID-19.

CONCLUSIONS

This study demonstrated the need for greater public health support, as well as the role of Social Determinants of Health. Understanding perceptions and reactions to COVID-19 can help public health nurses understand and better respond to future pandemics.