Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico

Screening tools for employment in clinical healthcare delivery systems: a content analysis

BACKGROUND

The relationship between work and health is complex and bidirectional, where work can have both health-harming and health-enhancing effects. Though employment is recognized as a social determinant of health, and clinical healthcare delivery systems are increasingly using screening tools to ask patients about social needs, little research has explored the extent to which employment-related social risk is captured in these screening tools. This study aimed to identify and characterize employment- and work-related questions in social risk screening tools that have been implemented in clinical healthcare delivery systems.

METHODS

We conducted a qualitative content analysis of employment-related items in screening tools that have been implemented in clinical healthcare service delivery systems. Three content areas guided data extraction and analysis: Setting, Domain, and Level of Contextualization.

RESULTS

Screening tools that asked employment-related questions were implemented in settings that were diverse in the populations served and the scope of care provided. The intent of employment-related items focused on four domains: Social Risk Factor, Social Need, Employment Exposure, and Legal Need. Most questions were found to have a low Level of Contextualization and were largely focused on identifying an individual's employment status.

CONCLUSIONS

Several existing screening tools include measures of employment-related social risk, but these items do not have a clear purpose and range widely depending on the setting in which they are implemented. In order to maximize the utility of these tools, clinical healthcare delivery systems should carefully consider what domain(s) they aim to capture and how they anticipate using the screening tools to address social determinants of health.

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.

Development of a comprehensive survey to assess key socioecological determinants of health

BACKGROUND

Although disparities in surgical outcomes are well-documented, our understanding of how socioecological factors drive these disparities remains limited. Comprehensive and efficient assessment tools are needed. This study's objective was to develop and assess the acceptability and feasibility of a comprehensive tool evaluating socioecological determinants of health in patients requiring colorectal surgery.

METHODS

In the first phase, a comprehensive socioecological determinant of health assessment tool was developed. A review of validated socioecological health evaluation instruments was conducted, and a 2-step modified Delphi method addressed the length, clarity, appropriateness, and redundancy of each instrument. A comprehensive tool was then finalized. In the second phase, the tool was tested for acceptability and feasibility in adult patients requiring colorectal surgery using a theory-guided framework at 3 Alabama hospitals. Relationships between survey responses and measures of acceptability and feasibility were evaluated using results from initial pilot tests of the survey.

RESULTS

In Phase 1, a modified Delphi process led to the development of a comprehensive tool that included 31 socioecological determinants of health (88 questions). Results of acceptability and feasibility were globally positive (>65%) for all domains. Overall, 83% of participants agreed that others would have no trouble completing the survey, 90.4% of respondents reported the survey was not burdensome, 97.6% of patients reported having enough time to complete the survey, and 80.9% agreed the survey was well-integrated into their appointment.

CONCLUSION

An 88-item assessment tool measuring 31 socioecological determinants of health was developed with high acceptability and feasibility for patients who required colorectal surgery. This work aids in the development of research needed to understand and address surgical disparities.

Discussing systemic racism and racial privilege at a large, academic health center using a modified privilege walk

BACKGROUND

There is a motivation for organizations to understand race and racism from the perspective of minoritized individuals. Academic health centers (AHC) are ideal organizations to have these conversations as they educate healthcare providers, support research in health disparities, and care for diverse patients.

METHODS

We piloted and evaluated a virtual Modified Privilege Walk (MPW) with faculty, staff, and students at an AHC in July 2020 to promote difficult conversations about race/racism, social class, and privilege. Each MPW session was voluntary, held virtually over Zoom, and lasted one hour and thirty minutes. Before attending, participants answered questions based on their race/ethnicity and social class to calculate a "privilege score." After each session, attendees were asked to complete an evaluation survey.

RESULTS

There were five virtual MPWs with 132 attendees, and 74 participants completed an evaluation survey (56% response rate). Many respondents were students (n = 29, 39.2%). Most respondents either agreed (n = 36, 48.6%) or strongly agreed (n = 32, 43.2%) that the virtual MPW positively impacted how they will interact with those of a different race/ethnicity. Attendees requested having more virtual MPWs with leadership, incorporating virtual MPWs in various program curricula, and requiring new employees to participate.

CONCLUSIONS

American organizations, particularly AHCs, should provide safe spaces and support these discussions surrounding race and racism as many were founded, built, or operated during a time of free labor and segregation that exerted power and control over minoritized individuals. Authors provide recommendations to dismantle organizational racism and support minoritized employees, patients, and students.

ACORN SDOH survey: Terminological representation for use with NLP and CDS

Objective

Social Determinants of Health (SDOH) greatly influence health outcomes. SDOH surveys, such as the Assessing Circumstances & Offering Resources for Needs (ACORN) survey, have been developed to screen for SDOH in Veterans. The purpose of this study is to determine the terminological representation of the ACORN survey, to aid in natural language processing (NLP).

Methods

Each ACORN survey question was read to determine its concepts. Next, Solor was searched for each of the concepts and for the appropriate attributes. If no attributes or concepts existed, they were proposed. Then, each question's concepts and attributes were arranged into subject-relation-object triples.

Results

Eleven unique attributes and 18 unique concepts were proposed. These results demonstrate a gap in representing SDOH with terminologies. We believe that using these new concepts and relations will improve NLP, and thus, the care provided to Veterans.

Addressing Social Determinants of Health in Family Medicine Practices

Primary care practices are under pressure to address patients' social determinants of health (SDOH). However, the extent to which these practices have this ability remains unknown. The objective of this study was to examine the association between physician, practice, and community characteristics and the ability of family medicine practices to address patients' SDOH. This cross-sectional study used data from the American Board of Family Medicine Continuing Certification Questionnaire from 2017 to 2019, with a 100% response rate. Respondents rated their practice's ability to address SDOH, which was dichotomized as high or low. Sequential multivariate logistic regression determined the association of the reported ability to address SDOH with physician, practice, and community characteristics. Among 19,300 respondents, 55.6% reported a high ability to address patients' SDOH. Across models controlling for different groups of variables, characteristics persistently positively associated with ability to address SDOH included employment at a federally qualified health center (Odds Ratios [OR] = 2.111-3.012), federally funded clinic (OR = 1.999-2.897), managed care organization (OR = 2.038-2.303), and working collaboratively with a social worker (OR = 2.000-2.523) or care coordinator (OR = 1.482-1.681). Characteristics persistently negatively associated with the ability to address SDOH were practicing at an independently owned (OR = 0.726-0.812) or small practice (OR = 0.512-0.863). While results varied across models, these findings are important for developing evidence-based policies and recommendations for resource sharing and allocation in clinics and communities. Ensuring availability and access to allied health professionals and community resources may be key components in Family Medicine clinics addressing SDOH.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

Screening for the social determinants of health: Referring patients to community-based services

BACKGROUND

Screening patients for the social determinants of health (SDOH) allows clinicians to identify those needs and tailor referral efforts. Due to constraints on clinic time and monetary resources, a simple screening tool incorporated into existing clinic workflow increases its usefulness and impact.

LOCAL PROBLEM

Our free, nurse-led, mobile health clinic (MHC) needed an enhanced process or tool for screening patients for SDOH. The purpose of this quality-improvement project was to screen adult patients in the MHC for SDOH needs and to increase volunteer staff perceptions of their knowledge and confidence in referring patients to relevant community-based services.

METHODS

A screening process and tool was developed using guidelines from the Health Leads to identify patients' SDOH needs and related requests for assistance. The tool was introduced to and tested among volunteer staff through pretest/posttest surveys.

INTERVENTIONS

Patients who visited the clinic were screened for the SDOH within the project period, and volunteer staff were surveyed about their perceptions of the screening tool.

RESULTS

Sixty-four patients were screened for SDOH needs. Twenty-three percent reported food insecurity, 27% housing insecurity, 14% difficulty obtaining utilities, and 17% difficulty obtaining transportation; 28% requested assistance with their reported SDOH needs. Seventeen percent of patients reported two or more SDOH needs. At posttest, 100% of volunteer staff ( N = 9) indicated satisfaction with the SDOH screening questions, reported feeling knowledgeable about resources to use for patient referrals, and were confident in referring patients to needed resources.

CONCLUSION

The screening tool aptly guided practice and was evaluated as "easy to use" for clinic patients and volunteer staff.

Telephone-based social health screening by pharmacists in the nonadherent Medicare population

BACKGROUND: Unmet social health needs are associated with medication nonadherence. Although pharmacists are well positioned to address medication nonadherence, there is limited experience with screening for and addressing social health needs. OBJECTIVES: To compare the prevalence of social health needs among Medicare patients with higher vs lower social health risk using a predictive model. To also evaluate pre-post changes in medication adherence and health care use following a pharmacist-initiated social health screening. METHODS: A social health screening workflow was implemented into a routine pharmacist adherence program at an integrated health care delivery system. The social health screening was conducted during medication adherence outreach phone calls with Medicare members who were overdue for statin, blood pressure, or diabetes medications. We developed a social health need predictive algorithm to flag higher-risk patients and tested this algorithm against a random subset of lower-risk patients. Screening conversations were guided by a focus group that developed open-ended questions to identify social health needs. Comparisons in social health needs were made between higher- and lower-risk patients. Use and adherence outcomes were compared pre and post for patients who accepted a referral to social health resources and patients who declined a referral. RESULTS: 1,217 patients were contacted and screened for social health needs by pharmacists. Patients flagged by the social risk algorithm were more likely to report social health needs (28.7% vs 12.7% in the unflagged group; P < 0.01). Commonly reported needs included transportation (43%), finances (34%), caregiving (22%), mental health (11%), and food access (10%). 221 patients accepted a referral to a central resource website and call center that connected patients to local services. One year after screening dates, patients who did not accept a referral spent more time in the hospital (mean change +0.7 days, SD = 7.3, P < 0.01), had fewer primary care visits (mean change -0.5 visits, SD = 6.5, P < 0.01), and had a shorter length of membership (mean change -0.4 months, SD = 1.9, P < 0.01). Patients who accepted a referral had increased statin adherence (62.3% adherent pre vs 74.7% post, P = 0.02). CONCLUSIONS: We implemented a workflow for pharmacists to screen for social health needs. The social health need prediction model doubled the identification rate of patients who have needs. Intervening on social health needs during these calls may improve statin adherence and may have no adverse effect on health care utilization or health plan membership. DISCLOSURES: Social health risk predictive model development and validation was funded by the Agency for Healthcare Research and Quality (AHRQ R18HS027343).

Implementing a Social Needs Screening and Referral Program Among Veterans: Assessing Circumstances & Offering Resources for Needs (ACORN)

BACKGROUND

The Department of Veterans Affairs (VA) healthcare system routinely screens Veterans for food insecurity, housing instability, and intimate partner violence, but does not systematically screen for other health-related social needs (HRSNs).

OBJECTIVES

To (1) develop a process for systematically identifying and addressing Veterans' HRSNs, (2) determine reported prevalence of HRSNs, and (3) assess the acceptability of HRSN screening among Veterans.

DESIGN

"Assessing Circumstances and Offering Resources for Needs" (ACORN) is a Veteran-tailored HRSN screening and referral quality improvement initiative. Veterans were screened via electronic tablet for nine HRSNs (food, housing, utilities, transportation, legal needs, social isolation, interpersonal violence, employment, and education) and provided geographically tailored resource guides for identified needs. Two-week follow-up interviews with a purposive sample of Veterans explored screening experiences.

PARTICIPANTS

Convenience sample of Veterans presenting for primary care at a VA urban women's health clinic and suburban community-based outpatient clinic (October 2019-May 2020).

MAIN MEASURES

Primary outcomes included prevalence of HRSNs, Veteran-reported acceptability of screening, and use of resources guides. Data were analyzed using descriptive statistics, chi-square tests, and rapid qualitative analysis.

KEY RESULTS

Of 268 Veterans screened, 50% reported one or more HRSNs. Social isolation was endorsed most frequently (29%), followed by educational needs (19%), interpersonal violence (12%), housing instability (9%), and utility concerns (7%). One in five Veterans reported at least one form of material hardship. In follow-up interviews (n = 15), Veterans found screening acceptable and felt VA should continue screening. No Veterans interviewed had contacted recommended resources at two-week follow-up, although several planned to use resource guides in the future.

CONCLUSION

In a VA HRSN screening and referral program, Veterans frequently reported HRSNs, felt screening was important, and thought VA should continue to screen for these needs. Screening for HRSNs is a critical step towards connecting patients with services, identifying gaps in service delivery, and informing future resource allocation.

Design of CLARO+ (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses, Plus): A randomized trial of collaborative care to decrease overdose and suicide risk among patients with co-occurring disorders

BACKGROUND

The United States is mired in two intertwined epidemics of death from suicide and overdose. Opioid use disorder (OUD) and mental illness contribute to both, and individuals with co-occurring disorders (CODs) are a complex population at high risk. Although universal prevention makes sense from a public health perspective, medical and behavioral health providers often lack the time to proactively address these issues with all patients. In this study, we build upon a parent study called Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO), a model of collaborative care in which care coordinators deliver preventative measures to high-risk patients and coordinate care with the patients' care team, with the goal of increasing MOUD retention and decreasing risk of suicide and overdose.

METHODS

CLARO+ adds intervention components on overdose prevention, recognition, and response training; lethal means safety counseling; and an effort to mail compassionate messages called Caring Contacts. Both CLARO and CLARO+ have been implemented at 17 clinics in New Mexico and California, and this study seeks to determine the difference in effectiveness between the two versions of the intervention. This paper describes the design protocol for CLARO+.

CONCLUSION

CLARO+ is an innovative approach that aims to supplement existing collaborative care with additional suicide and overdose prevention strategies.

CLINICALTRIALS

gov: NCT04559893.

Models of social prescribing to address non-medical needs in adults: a scoping review

BACKGROUND

The health and wellbeing consequences of social determinants of health and health behaviours are well established. This has led to a growing interest in social prescribing, which involves linking people to services and supports in the community and voluntary sectors to address non-medical needs. However, there is considerable variability in approaches to social prescribing with little guidance on how social prescribing could be developed to reflect local health systems and needs. The purpose of this scoping review was to describe the types of social prescribing models used to address non-medical needs to inform co-design and decision-making for social prescribing program developers.

METHODS

We searched Ovid MEDLINE(R), CINAHL, Web of Science, Scopus, National Institute for Health Research Clinical Research Network, Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registry Platform, and ProQuest - Dissertations and Theses for articles and grey literature describing social prescribing programs. Reference lists of literature reviews were also searched. The searches were conducted on 2 August 2021 and yielded 5383 results following removal of duplicates.

RESULTS

148 documents describing 159 social prescribing programs were included in the review. We describe the contexts in which the programs were delivered, the program target groups and services/supports to which participants were referred, the staff involved in the programs, program funding, and the use of digital systems.

CONCLUSIONS

There is significant variability in social prescribing approaches internationally. Social prescribing programs can be summarised as including six planning stages and six program processes. We provide guidance for decision-makers regarding what to consider when designing social prescribing programs.

Social Determinants of Health and Impact in Perioperative Space

The Centers for Disease Control and Prevention (CDC) defines the social determinants of health (SDOH) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a range of health, functioning, and quality-of-life outcomes and risks," which includes economic stability, access to quality health care, and physical environment. There is increasing evidence that SDOH have an impact in shaping a patient's access and recovery from surgery. This review evaluates the role surgeons play in reducing these disparities.

Social risk factors among individuals with a history of cancer during the COVID-19 pandemic

PURPOSE

The coronavirus disease (COVID-19) pandemic and its economic consequences may disproportionately impact cancer survivors and their overall health-related quality of life. The objective of this study was to examine whether cancer survivors experienced higher levels of financial strain or food insecurity compared to those without a history of cancer.

METHODS

Kaiser Permanente Research Bank (KPRB) study participants were invited to complete a series of electronic surveys starting April 2020 to assess the impact of the COVID-19 pandemic. Participants who completed the initial survey and one follow-up survey were included. The odds of financial strain and food insecurity in those with and without a history of cancer were estimated using multinomial logistic regression.

RESULTS

Cancer survivors (n = 16,231) had lower odds of reporting "somewhat hard" (AOR = 0.77) and "very hard" (AOR = 0.67) financial strain, and food insecurity "sometimes" (AOR = 0.70) and "often" (AOR = 0.55) compared to those with no history of cancer (n = 88,409). Non-Hispanic (NH) Black and Hispanic cancer survivors had higher odds compared to NH Whites of reporting financial strain and food insecurity. Smokers and those with multiple comorbidities had higher odds of reporting financial strain and food insecurity among cancer survivors.

CONCLUSIONS

While cancer survivors overall did not report greater financial strain or food insecurity than individuals without a history of cancer, subsets of cancer survivors are experiencing greater social risks during the pandemic and should be prioritized for screening for social risk factors.

IMPLICATIONS FOR CANCER SURVIVORS

Incorporating screening for social risk factors into care coordination workflows for subsets of cancer survivors should be a priority.

Using adult learning characteristics and the humanities to teach undergraduate healthcare students about social determinants of health

Authors used an andragogy framework to help undergraduate allied health students better understand social determinants of health (SDOH) using a photo essay assignment. The study examined students' perceptions of SDOH in various communities, description of health outcomes associated with their chosen SDOH, and lessons learned and suggestions to improve the assignment for future cohorts. Data were extracted from photo essays from 2019-2021 and entered in Microsoft Excel and Word for data analysis after course completion. Conventional qualitative content analysis was used to analyze student evaluation data from open-ended questions. Data were extracted from 53 student essays from 2019 to 2021. Most photo essays described communities in South Carolina (n = 42, 79.2%), urban areas (n = 37, 69.8%), or intermediary SDOH (75.5%). Several themes emerged concerning lessons learned (awareness and empathy are key to addressing SDOH), health equity (collaboration is necessary to provide resources, especially for underserved populations), and constructive feedback for the instructor (more time to discuss SDOH and assignment with peers and instructor). Faculty must work with students to think about more upstream factors like policy and cultural and societal values. Collecting evaluation data, specifically lessons learned and constructive feedback for faculty, can help faculty continuously improve course topics and assignments. Following a transparency framework can support student success and help faculty become effective leaders in the classroom while teaching subjects like SDOH and social justice.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

BACKGROUND

Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease.

OBJECTIVE

Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes.

DESIGN

Observational cohort study.

PARTICIPANTS

One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021.

INTERVENTIONS

Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support).

MAIN MEASURES

Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations).

KEY RESULTS

Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months.

CONCLUSIONS

CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Academic Medicine's Fourth Mission: Building on Community-Oriented Primary Care to Achieve Community-Engaged Health Care

A 2021 article, "Now is our time to act: Why academic medicine must embrace community collaboration as its fourth mission," by Association of American Medical Colleges (AAMC) authors, including AAMC president and CEO Dr. David J. Skorton, offers 2 aims that are highly related: community collaboration and health equity. The AAMC's call to prioritize community collaboration and health equity as pillars of the academic medicine mission echo earlier work on community-oriented primary care (COPC) and an even more robust model that builds on COPC, community-engaged health care (CEHC). COPC is a tested, systematic approach to health care by which a health clinic or system collaborates with a community to reshape priorities and services based on assessed health needs and determinants of health. COPC affirms health inequities' socioeconomic and political roots, emphasizing health care as a relationship, not a transaction or commodity. Communities where COPC is implemented often see reductions in health inequities, especially those related to socioeconomic, structural, and environmental factors. COPC was the foundation on which community health centers were built, and early models had demonstrable effects on community health and engagement. Several academic health centers build on COPC to achieve CEHC. In CEHC, primary care remains critical, but more of the academic health center's functions are pulled into community engagement and trust building. Thus, the AAMC has described and embraced a care and training model for which there are good, longitudinal examples among medical schools and teaching hospitals. Spreading CEHC and aligning the Community Health Needs Assessment requirements of academic health centers with the fourth mission could go a long way to improving equity, building trust, and repairing the social contract for health care.

Considerations in implementation of social risk factor screening and referral in maternal and infant care in Washington, DC: A qualitative study

BACKGROUND

The District of Columbia (DC) has striking disparities in maternal and infant outcomes comparing Black to White women and babies. Social determinants of health (SDoH) are widely recognized as a significant contributor to these disparities in health outcomes. Screening for social risk factors and referral for appropriate services is a critical step in addressing social needs and reducing outcome disparities.

METHODS

We conducted interviews among employees (n = 18) and patients (n = 9) across three diverse, urban clinics within a healthcare system and one community-based organization involved in a five-year initiative to reduce maternal and infant disparities in DC. Interviews were guided by the Consolidated Framework for Implementation Research to understand current processes and organizational factors that contributed to or impeded delivery of social risk factor screening and referral for indicated needs.

RESULTS

We found that current processes for social risk factor screening and referral differed between and within clinics depending on the patient population. Key facilitators of successful screening included a supportive organizational culture and adaptability of more patient-centered screening processes. Key barriers to delivery included high patient volume and limited electronic health record capabilities to record results and track the status of internal and community referrals. Areas identified for improvement included additional social risk factor assessment training for new providers, patient-centered approaches to screening, improved tracking processes, and facilitation of connections to social services within clinical settings.

CONCLUSION

Despite proliferation of social risk factor screeners and recognition of their importance within health care settings, few studies detail implementation processes for social risk factor screening and referrals. Future studies should test implementation strategies for screening and referral services to address identified barriers to implementation.

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.

Incorporating social determinants of health into individual care—a multidisciplinary perspective of health professionals who work with people who have type 2 diabetes

Social determinants of health (SDoH) and type 2 diabetes mellitus (T2DM) are interrelated. The prevalence of T2DM is increased amongst those with suboptimal SDoH. Poor SDoH can also negatively impact T2DM self-management. Social determinants of health are mostly considered at population and community levels, rather than individually or clinically. This qualitative study combines the perspectives of a multidisciplinary cohort of health professionals to identify and explore the impact of social determinants on self-management, and ways they could be incorporated into individual clinical care. Purposively selected participants chose to partake in an in-depth, semi-structured, one-on-one interview or focus group. Data were analysed, and themes identified using a combination of deductive and inductive thematic analysis. Fifty-one health professionals volunteered for the study. Two small focus groups (n = 3 and n = 4) and 44 one-on-one interviews were conducted. The identified themes were: 1) Support for incorporating SDoH into T2DM care, 2) Effect of SDoH on T2DM self-management, 3) Identifying and addressing social need, 4) Requirements for incorporating SDoH into T2DM individual clinical care. Health professionals reported that poor social determinants negatively affect an individual’s ability to self manage their T2DM. Person-centred care could be enhanced, and people with T2DM may be more likely to achieve self-management goals if SDoH were included in individual clinical care. To achieve successful and sustained self-management for people with T2DM, health professionals require a thorough understanding of T2DM and the effect of social determinants, respect for client privacy, client trust and rapport, effective communication skills, validated tools for assessing SDoH, team champions, teamwork, ongoing education and training, adequate resources, guiding policies and procedures, and management support. Incorporating SDoH into individual, clinical care for people with T2DM was strongly supported by health professionals. If embraced, this addition to care for individuals with T2DM could improve self-management capacity and enhance person-centred care.

Addressing Social Risk Factors in the Inpatient Setting: Initial Findings from a Screening and Referral Pilot at an Urban Safety-Net Academic Medical Center in Virginia, USA

Social Determinants of Health (SDOH) impact health outcomes; thus, a pilot to screen for important SDOH domains (food, housing, and transportation) and address social needs in hospitalized patients was implemented in an urban safety-net academic medical center. This study describes the pilot implementation and examines patient characteristics associated with SDOH-related needs. An internal medicine unit was designated as a pilot site. Outreach workers approached eligible patients (n = 1,135) to complete the SDOH screening survey at time of admission with 54% (n = 615) completing the survey between May 2019 and July 2020. Data from patient screening survey and electronic health records were linked to allow for examination of associations between SDOH needs for food, housing, and transportation and various demographic and clinical characteristics of patients in multivariate logistic regression models. Of 615 screened patients, 45% screened positive for any need. Of 275 patients with needs, 33% reported needs in 2, and 34% – in 3 domains. Medicaid beneficiaries were more likely than patients with private health insurance to screen positive for 2 and 3 needs; Black patients were more likely than White patients to screen positive for 1 and 3 needs; Patients with no designated primary care physician status screened positive for 1 need; Patients with a history of substance use disorder screened positive for all 3 needs. SDOH screening assisted in addressing social risk factors of inpatients, informed their discharge plans and linkage to community resources. SDOH screening demonstrated significant correlations of positive screens with race/ethnicity, insurance type, and certain clinical characteristics.

Addressing Social Needs in the Clinical Setting: Description of Needs Identified in a Quality Improvement Pilot Across 3 Community Hospital Service Areas

Describe patient social needs in a large midwestern health care system. Health care systems are increasingly interested in addressing social needs in the clinical setting for improved health outcomes and lower costs. This retrospective cross-sectional analysis of health records data was a population health pilot project which tested a digital platform to screen and refer patients for social needs across three community hospitals serving Chicago and its South Suburbs. The analysis reports on social needs identified based on the referrals made. Electronic health record data were linked to the referral data to describe patient clinical and demographic characteristics. A total of 2909 patients had at least 1 social need identified. The mean age was 49 years ±21.7 and 65.7% were women. Only 33% of patients had 1 social need identified, indicating that if a social need is identified for patients, they most likely have social needs from other categories as well. Patients of color, specifically African American patients, were 14% more likely to have at least 3 social need categories identified (95% confidence interval of relative risk: 1.02-1.29). Financial stability was the most commonly reported social need (50.7%), followed by food and nutrition (43%). Transportation (22%) and housing (21%) were also commonly reported. This population health initiative reveals that many patients accessing health care have multiple social needs that can be identified at the point of care, and patterns of need-based referral vary by patient clinical and demographic characteristics.

Gathering Health Perspectives of the Justice Involved: A Multisite Needs Assessment Survey

The well-being of justice-involved individuals must be of high priority to achieve health equity, reduce health disparities, and improve community health. To better understand the health interests and needs of justice-involved individuals, a survey was administered inquiring about health information-seeking behavior and health topics of interest. The survey was administered using secure tablet computers and completed by 1,888 incarcerated participants in 35 jails in 17 states. Salient themes that emerged from this research include the relatively equal use of the internet and health care providers as resources for health information; the extensive interest in learning about multiple health care topics; and demographic variations in health information-seeking behaviors and health topics of interest. Tailoring correctional health education programs to coincide with the interests and needs of the justice-involved population may attract more participants and thus result in better self-care management skills and health outcomes upon reentering communities.

Identifying facilitators, barriers, and strategies to implement social determinants of health screening, referral, and follow-up in the US: a scoping review protocol

OBJECTIVE

This review will assess the literature exploring facilitators, barriers, and strategies for the implementation of social determinants of health and social needs screening, referral to community resources, and follow-up in clinical settings and clinical training curricula in the United States.

INTRODUCTION

Social determinants of health and social needs are a central cause of health inequity and poor health outcomes in the United States. Existing research primarily focuses on theoretical implications of social determinants of health on health outcomes, with a growing secondary focus on the development of screening tools that identify patients' specific unmet social needs. However, summative research has not yet focused on the barriers, facilitators, and strategies relating to the implementation of social determinants of health and social need screenings into routine clinical care. This scoping review aims to examine literature on the implementation of social determinants of health and social needs screening in clinical settings and clinical training curricula while also identifying gaps that require further exploration.

INCLUSION CRITERIA

This review will include relevant studies examining the facilitators, barriers, and strategies for the implementation of social determinants of health and social needs screening, referral, and follow-up as they relate to human subjects. The literature must be in English from 2010 and focus on United States clinical health settings and curricula.

METHODS

We will search PubMed, CINAHL, and Embase databases for relevant articles. Two independent reviewers will screen abstracts for eligibility. Data will be extracted from eligible articles and results will be presented in narrative and tabular format in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

Low housing quality, unmet social needs, stress and depression among low-income smokers

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Over 60% of low-income smokers reported housing quality problems.

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Problems with housing quality were among the most common social needs.

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Housing quality problems were associated with worse measures of health.

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Poor housing quality may exacerbate health disparities for low-income smokers.

Smokers are at greater risk of multiple health conditions that are exacerbated by environmental hazards associated with low housing quality. However, little is known about the prevalence of low housing quality among low-income smokers. Using correlations and logistic regression, we examined associations among eight housing quality indicators – pests, water leaks, mold, lead paint, and working smoke detectors, appliances, heating, and air conditioning – and between housing quality and social needs, depressive symptoms, perceived stress, sleep problems, and self-rated health in a community-based sample of 786 low-income smokers from 6 states. Most participants were female (68%), and White (45%) or African-American (43%). One in four (27%) completed less than high school education, and 41% reported annual pre-tax household income of less than $10,000. Housing quality problems were common. Most participants (64%) reported at least one problem in their home, and 41% reported two or more problems, most commonly pest infestations (40%), water leaks (22%), lack of air conditioning (22%) and mold (18%). Lack of heat and air conditioning were correlated, as were water leaks and mold. Using logistic regression analyses controlling for participant demographic characteristics, we found that reporting more housing quality problems was associated with greater odds of worse mental and physical health outcomes. Multiple health threats, including housing quality, depressive symptoms, stress, poor sleep, and financial strain may be mutually reinforcing and compound the health consequence of smoking. Future research should seek to replicate these findings in other samples, and examine associations longitudinally to better understand causality.

A Scoping Review and Narrative Synthesis Comparing the Constructs of Social Determinants of Health and Social Determinants of Mental Health: Matryoshka or Two Independent Constructs?

Background

Many health research policies invoke the construct of Social Determinants of Health, and more recently the construct of Social Determinants of Mental Health. While frequently referred to in the literature, it is unclear how these constructs relate to each other. Some commentators conceptualise the Determinants of Mental Health as a subgroup of the Determinants of general Health and others describe the Determinants of Mental Health as an autonomous construct. The current review investigates the relationship between both constructs.

Methods

Comprehensive literature searches were conducted for both constructs separately within seven electronic databases. A template analysis was conducted to compare the conceptualisations of the Social Determinants of Health and the Social Determinants of Mental Health.

Results

Of 4250 search results, 50 papers (25 for each construct) fulfilled our inclusion criteria and were incorporated into a narrative synthesis. Discussions of the Social Determinants of both general and Mental Health listed the same determinants. Both constructs were conceptualised on multiple levels and factors. Stress and health behaviour were also described as mediators for both constructs. The constructs differed, however, with respect to two components of their aetiologies and epistemologies. First, the causal mechanisms invoked for the Determinants of general Health followed predominantly direct pathways, in contrast to indirect pathways for the Social Determinants of Mental Health. Second, the Social Determinants of Mental Health were reported to influence mental health mediated through individuals' perceptions and appraisal processes. Appraisal processes were considered of far less relevance in the construct of Social Determinants of Health.

Conclusion

The constructs of Social Determinants of Health and Social Determinants of Mental Health align in many respects but differ on important aetiological and epistemological grounds. Similar social factors are considered important, but whereas physical health conditions are primarily conceptualised to be driven by objective realities, mental health is explained mainly in terms of perception of these realities. This differentiation between physical and mental health is in line with a modern understanding of mind-body-dualism, the naturalistic dualism after Chalmers. Differentiating the Social Determinants of Mental Health from the Social Determinants of Health might bear relevance for policy making and research.

Post-Identification Approaches to Addressing Health-Related Social Needs in Primary Care: A Qualitative Study

BACKGROUND

Social determinants of health play a fundamental role in a patient's health status. In recent years, health systems across the nation have implemented numerous strategies aimed at identifying and addressing the health-related social needs of the patients they serve. Despite the influx of peer-reviewed research highlighting outcomes of specific health-related social needs interventions, the spectrum of practices utilized by primary care clinics has not been established.

OBJECTIVE

To determine the range of ways primary care clinics address health-related social needs after identification and initial contact with a frontline staff person is completed.

DESIGN

We conducted 12 semi-structured, in-person interviews with staff from purposively sampled clinics. If the interview included more than one staff person, all participants were interviewed together.

PARTICIPANTS

Twenty-one administrative staff and frontline clinic personnel with experience in 24 separate primary care clinics in the Minneapolis-St. Paul, Minnesota metropolitan area.

APPROACH

Interviews focused on the range of health-related social needs processes utilized by clinics, including staff titles, referral procedures, and barriers to addressing needs. Interview recordings were transcribed and coded using thematic analysis.

KEY RESULTS

Thematic analysis identified variation in four key areas involving how clinics address patients' health-related social needs after identification and initial contact by frontline staff: clinic personnel involved in addressing needs, clinic referral processes, "resource" and "success" definitions, and barriers to accessing community-based supports.

CONCLUSIONS

This study describes the large variation in primary care clinic practices to address health-related social needs after they are identified. The results suggest challenges to standardization and real-world application of previously published studies. Our findings also highlight the opportunity for improved relationships between health systems and community-based agencies.

Adaptation of a social risk screening and referral initiative across clinical populations, settings, and contexts in the Department of Veterans Affairs Health System

Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks-RE-AIM, the Adaptome, and FRAME-to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.

Social health needs and promotive health factors scale for college students: Scale development and initial validation

Objective The psychometric properties of a measure of social determinants of health for college students entitled, The LIFESCREEN-C was developed. Participants: A sample of 226 college students completing an online survey during the 2018-2019 academic year. Methods: Tetrachoric correlations were used to confirm a three factor model. Results: Results found model fit; convergent validity with a measure of general health; and adequate internal reliability. Conclusions: The three model fit included: general social health needs, college student social health needs, and promotive social health factors. Implications for health professionals in college settings concludes.

Association Between Unmet Essential Social Needs and Influenza Vaccination in US Adults

BACKGROUND

Although social factors influence uptake of preventive services, the association between social needs and influenza vaccination has not been comprehensively evaluated for adults seeking primary care in the USA.

OBJECTIVE

To determine the association between unmet social needs and influenza vaccination.

DESIGN

Retrospective, cross-sectional, multivariable logistic regression.

PARTICIPANTS

Persons completing ambulatory visits in a primary care department at a midwestern, urban, multispecialty, academic medical center between July 2017 and July 2019 (N = 7955 individuals included).

MAIN MEASURES

Completion of influenza vaccination in the 2018-2019 influenza season (primary outcome) or any year (secondary outcome) against 11 essential social needs (childcare, companionship, food security, health literacy, home safety, neighborhood safety, housing, health care provider costs, prescription costs, transportation, and utilities). Demographics, diabetic status, COPD, smoking status, office visit frequency, and hierarchical condition category risk scores were included as covariates.

KEY RESULTS

Individuals with transportation vulnerability were less likely to be vaccinated against influenza (current-year aOR 0.65, 95% CI: 0.53-0.78, p < 0.001; any-year aOR 0.58, 95% CI: 0.47-0.71, p < 0.001). Poor health literacy promoted any-year, but not current-year, influenza vaccination (any-year aOR 1.30, 95% CI: 1.01-1.69, p = 0.043). Older age, female sex, diabetes, more comorbidities, and more frequent primary care visits were associated with greater influenza vaccination. Persons with Black or other/multiple race and current smokers were less frequently vaccinated.

CONCLUSIONS

Transportation vulnerability, health literacy, smoking, age, sex, race, comorbidity, and office visit frequency are associated with influenza vaccination. Primary care-led interventions should consider these factors when designing outreach interventions.

TRIAL REGISTRATION

Not applicable.

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic

BACKGROUND

There is increased recognition in clinical settings of the importance of documenting, understanding, and addressing patients' social determinants of health (SDOH) to improve health and address health inequities. This study evaluated a pilot of a standardized SDOH screening questionnaire and workflow in an ambulatory clinic within a large integrated health network in Northern California.

METHODS

The pilot screened for SDOH needs using an 11-question Epic-compatible paper questionnaire assessing eight SDOH and health behavior domains: financial resource, transportation, stress, depression, intimate partner violence, social connections, physical activity, and alcohol consumption. Eligible patients for the pilot receiving a Medicare wellness, adult annual, or new patient visits during a five-week period (February-March, 2020), and a comparison group from the same time period in 2019 were identified. Sociodemographic data (age, sex, race/ethnicity, and payment type), visit type, length of visit, and responses to SDOH questions were extracted from electronic health records, and a staff experience survey was administered. The evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

RESULTS

Two-hundred eighty-nine patients were eligible for SDOH screening. Responsiveness by domain ranged from 55 to 67%, except for depression. Half of patients had at least one identified social need, the most common being stress (33%), physical activity (22%), alcohol (12%), and social connections (6%). Physical activity needs were identified more in females (81% vs. 19% in males, p < .01) and at new patient/transfer visits (48% vs. 13% at Medicare wellness and 38% at adult wellness visits, p < .05). Average length of visit was 39.8 min, which was 1.7 min longer than that in 2019. Visit lengths were longer among patients 65+ (43.4 min) and patients having public insurance (43.6 min). Most staff agreed that collecting SDOH data was relevant and accepted the SDOH questionnaire and workflow but highlighted opportunities for improvement in training and connecting patients to resources.

CONCLUSION

Use of evidence-based SDOH screening questions and associated workflow was effective in gathering patient SDOH information and identifying social needs in an ambulatory setting. Future studies should use qualitative data to understand patient and staff experiences with collecting SDOH information in healthcare settings.

Assessment of patient navigation programs for breast cancer patients across the city of Boston

PURPOSE

Healthcare systems contribute to disparities in breast cancer outcomes. Patient navigation is a widely cited system-based approach to improve outcomes among populations at risk for delays in care. Patient navigation programs exist in all major Boston hospitals, yet disparities in outcomes persist. The objective of this study was to conduct a baseline assessment of navigation processes at six Boston hospitals that provide breast cancer care in preparation for an implementation trial of standardized navigation across the city.

METHODS

We conducted a mixed methods study in six hospitals that provide treatment to breast cancer patients in Boston. We administered a web-based survey to clinical champions (n = 7) across six sites to collect information about the structure of navigation programs. We then conducted in-person workflow assessments at each site using a semi-structured interview guide to understand site-specific implementation processes for patient navigation programs. The target population included administrators, supervisors, and patient navigators who provided breast cancer treatment-focused care.

RESULTS

All sites offered patient navigation services to their patients undergoing treatment for breast cancer. We identified wide heterogeneity in terms of how programs were funded/resourced, which patients were targeted for navigation, the type of services provided, and the continuity of those services relative to the patient's cancer treatment.

CONCLUSIONS

The operationalization of patient navigation varies widely across hospitals especially in relation to three core principles in patient navigation: providing patient support across the care continuum, targeting services to those patients most likely to experience delays in care, and systematically screening for and addressing patients' health-related social needs. Gaps in navigation across the care continuum present opportunities for intervention.

TRIAL REGISTRATION

Clinical Trial Registration Number NCT03514433, 5/2/2018.

Routinely asking patients about income in primary care: a mixed-methods study

Background

Income is a key social determinant of health, yet it is rare for data on income to be routinely collected and integrated with electronic health records.

Aim

To examine response bias and evaluate patient perspectives of being asked about income in primary care.

Design & setting

Mixed-methods study in a large, multi-site primary care organisation in Toronto, Canada, where patients are asked about income in a routinely administered sociodemographic survey.

Method

Data were examined from the electronic health records of patients who answered at least one question on the survey between December 2013 and March 2016 (n = 14 247). The study compared those who responded to the income question with non-responders. Structured interviews with 27 patients were also conducted.

Results

A total of 10 441 (73%) patients responded to both parts of the income question: ‘What was your total family income before taxes last year?’ and ‘How many people does your income support?’. Female patients, ethnic minorities, caregivers of young children, and older people were less likely to respond. From interviews, many patients were comfortable answering the income question, particularly if they understood the connection between income and health, and believed the data would be used to improve care. Several patients found it difficult to estimate their income or felt the options did not reflect fluctuating financial circumstances.

Conclusion

Many patients will provide data on income in the context of a survey in primary care, but accurately estimating income can be challenging. Future research should compare self-reported income to perceived financial strain. Data on income linked to health records can help identify health inequities and help target anti-poverty interventions.

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature

BACKGROUND

It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it.

PURPOSE OF STUDY

This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation.

METHODS

Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes.

RESULTS

Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs.

CONCLUSION

Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

Call to Action: Addressing Social Determinants of Health in Pharmacy Practice

Social determinants of health (SDOH) are conditions in which individuals are born, live, work, learn, play, and age that affect health, risks, functioning, and outcomes. SDOH are recognized barriers to care, risk factors for certain diseases, and associated with poorer health outcomes. Screening for SDOH in physician practices and hospitals is reportedly low. The accessibility of pharmacists and established relationships with patients make pharmacy settings ideal for identifying and mitigating social needs. An evaluation of the impact of SDOH on health outcomes and opportunities for pharmacists to embed screening into practice is warranted.

Practical Opportunities for Biopsychosocial Education Through Strategic Interprofessional Experiences in Integrated Primary Care

Even with the expansion of primary care teams to include behavioral health and other providers from a range of disciplines, providers are regularly challenged to deliver care that adequately addresses the complex array of biopsychosocial factors underlying the patient's presenting concern. The limits of expertise, the ever-changing shifts in evidence-based practices, and the difficulties of interprofessional teamwork contribute to the challenge. In this article, we discuss the opportunity to leverage the interprofessional team-based care activities within integrated primary care settings as interactive educational opportunities to build competencies in biopsychosocial care among primary care team members. We argue that this approach to learning while providing direct patient care not only facilitates new provider knowledge and skills, but also provides a venue to enhance team processes that are key to delivering integrated biopsychosocial care to patients. We provide three case examples of how to utilize strategic planning within specific team-based care activities common in integrated primary care settings-shared medical appointments, conjoint appointments, and team huddles-to facilitate educational objectives.

Workforce Models to Screen for and Address Patients' Unmet Social Needs in the Clinic Setting: A Scoping Review

Objectives

While healthcare organizations increasingly aim to address the social determinants of health (SDOH) in the clinic setting, there is little guidance on which staff are best equipped to assume this role. The present study is a scoping review of the peer-reviewed literature to characterize workforce models used to screen for and respond to patients’ unmet social needs in ambulatory settings.

Methods

Four online databases were used to identify papers published until February 2021. Eligible articles were original research studies or systematic reviews that described the implementation of a standardized assessment for multiple SDOH domains and resulting activities to respond to individual patient needs (eg, referral to community resources) in ambulatory care settings.

Results

Of the 1569 articles identified, 65 met study eligibility criteria. Majority of studies had observational study designs (11% were randomized control trials). For screening-related activities, more articles reported using traditional healthcare staff (51%), such as medical providers, medical assistants, and front-desk staff, than social care staff (32%), such as social workers and student volunteers. In contrast, for response-related activities, more articles reported using social care staff (88%) than traditional healthcare staff (60%). While we found wide variations in specific team configurations and training for the roles, social care staff generally provided more intensive forms of assistance than traditional healthcare staff.

Conclusion

While this review demonstrates the breadth of models for building or deploying a workforce to integrate health and social care, it also identifies the need for rigorous research on workforce development, implementation, and effectiveness.

A Broad-Based Approach to Social Needs Screening in a Pediatric Primary Care Network

OBJECTIVE

In 2016, the American Academy of Pediatrics recommended universally screening patients for social needs, and in 2018, a quality measure for social needs screening was included in some Massachusetts Medicaid contracts. However, exact guidelines for screening were not provided. We describe the results and implications from a broad-based health-related social needs (HRSN or "social needs") screening program within our large, pediatric primary care network.

METHODS

We adapted items from The Health Leads toolkit to create our network's screening tool: The Health Needs Assessment (HNA). We trained staff to use the tool and provided staff with resources to assist families with their needs. All patients with a primary care physician in the network were eligible to complete an HNA. We calculated descriptive statistics and estimated the risk of identifying a social need using multivariable regression analyses.

RESULTS

Between June 2018 and May 2019, 100,097 patients completed an HNA; 8% of patients identified a social need, and 33% of those patients requested assistance with the need(s). The multivariate analysis revealed an association between several patient characteristics-health insurance type, age, median household income by zip code, complex chronic conditions, race/ethnicity-and identifying a social need.

CONCLUSIONS

Our large, pediatric primary care network successfully instituted a broad-based HRSN screening program in response to state and national screening recommendations. We observed a low prevalence of reported social needs and a propensity to forego assistance. Additional research is needed to understand the barriers around the disclosure of social needs and requests for assistance.

Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health

There has been an explosion of interest in addressing social needs in health care settings. Some efforts, such as screening patients for social needs and connecting them to needed social services, are already in widespread practice. These and other major investments from the health care sector hint at the potential for new multisector collaborations to address social determinants of health and individual social needs. This article discusses the rapidly growing body of research describing the links between social needs and health and the impact of social needs interventions on health improvement, utilization, and costs. We also identify gaps in the knowledge base and implementation challenges to be overcome. We conclude that complementary partnerships among the health care, public health, and social services sectors can build on current momentum to strengthen social safety net policies, modernize social services, and reshape resource allocation to address social determinants of health.

Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes

OBJECTIVES

Despite advances in technology and type 1 diabetes (T1D) care, children from low-income families continue to have suboptimal outcomes and increased health-care utilization. In this study, we describe social determinants of health (SDOH) in high-risk children with T1D, as well as their SDOH-related priority goals, and assess the correlation between SDOH, glycemic control and health-care utilization.

METHODS

Caregivers of children aged 4 to 18 years with a diagnosis of T1D of >1 year, poor glycemic control (glycated hemoglobin [A1C] ≥9.5%) or high health-care utilization (≥2 diabetes-related hospitalizations, emergency department attendances or missed outpatient appointments in the previous year) were included. Primary caregiver health-related quality of life (HRQOL), self-efficacy (Maternal Self-Efficacy in Diabetes [MSED] scale) and SDOH were assessed. Goals were identified after assessment by a community health worker.

RESULTS

Fifty-three families were included, most (n=48, 91%) of whom had government insurance. Children had a median age of 13.4 (interquartile range [IQR], 12 to 15.3) years and a median A1C of 11.1% (IQR, 10% to 13%). Almost half of the families (n=24, 45%) reported at least 1 adverse SDOH. One or more adverse SDOH was associated with significantly lower total HRQOL scores (56.6 [IQR, 38.5 to 70.7] vs 77.8 [IQR, 60.8 to 92.4], p=0.004), but not associated with A1C (p=0.3), emergency department visits (p=0.9) or MSED (p=0.5).

CONCLUSIONS

Screening for adverse SDOH and addressing these barriers to glycemic control is not part of routine T1D care. In children with poorly controlled T1D and high health-care utilization, we have demonstrated a high prevalence of adverse SDOH, which may represent a modifiable factor to improve outcomes in this patient population.

A Review of Tools to Screen for Social Determinants of Health in the United States: A Practice Brief

Increasingly, health care institutions are called on to address social determinants of health (SDH) given the connection to morbidity and mortality across populations. However, widespread implementation of screening for health-related social conditions (HRSC) is lagging. It is estimated that half of patients who have such needs may be missed by failure to screen routinely. Health care institutions face gaps in information related to screening tools. A review of tools that screen for HRSC at the individual level is needed to share readily available and applicable tools for integration in various settings, to communicate how tools are typically administered, and to assess whether tools capture domains corresponding with Institute of Medicine (IOM) core measures. To address these gaps, an unsystematic rapid review of the literature was conducted. In addition to peer-reviewed literature, Google, PubMed, and CINAHL databases and grey literature were searched with a focus on lead agencies or scholars in the field. English language publications from 2008-2018 with content related to SDH or health-related social condition screening tools were included. Nine commonly applied tools were selected and reviewed for content, setting, and method of administration. Fifteen common domains were identified and assessed for alignment with IOM recommendations and correspondence with the construct of social stability. This review consolidates essential information about HRSC screening tools in 1 place and provides practice, policy, and research recommendations to improve HRSC screening. This review is a practice brief that can help health care institutions and clinicians implement screening and interventions related to HRSC.

Social Prescribing-An Effort to Apply a Common Knowledge: Impelling Forces and Challenges

In recent times, social prescribing has been introduced in some countries, and substantially in the U.K. The objective of this scheme is to offer non-medical care mainly to primary care patients. Although the idea of this scheme is not new, its formalization is. Using a narrative synthesis of peer-reviewed and gray literature, this article discusses the social prescribing scheme, some of its compelling aspects and challenges in offering non-medical care, particularly regarding referrals being made from primary care settings. The social prescribing scheme has several impelling forces that include its potential to turn primary care to primary healthcare, tackle social determinants of health and social needs, improve wellbeing and physical health, offer person-centered care, strengthen preventive care, and bridge healthcare organizations with the third sector. This scheme also faces several challenges including service standards and boundaries, sustainability, availability of appropriate services, low engagement of clients and insufficient evidence. While this scheme lacks validated evidence, it is theoretically compelling. Given that the demand for non-medical care is growing in most societies and that the usefulness of non-medical care is gaining prominence, social prescribing is likely to continue to proliferate.

Addressing social determinants of noncommunicable diseases in primary care: a systematic review

OBJECTIVE

To explore how primary care organizations assess and subsequently act upon the social determinants of noncommunicable diseases in their local populations.

METHODS

For this systematic review we searched the online databases of PubMed®, MEDLINE®, Embase® and the Health Management Information Consortium from inception to 28 June 2019, along with hand-searching of references. Studies of any design that examined a primary care organization assessing social determinants of noncommunicable diseases were included. For quality assessment we used Cochrane's tool for assessing risk of bias in non-randomized studies of interventions. We used narrative data synthesis to appraise the extent to which the assessments gathered data on the domains of the World Health Organization social determinants of health framework.

FINDINGS

We identified 666 studies of which 17 were included in the review. All studies used descriptive study designs. Clinic-based and household surveys and interviews were more commonly used to assess local social determinants than population-level data. We found no examples of organizations that assessed sociopolitical drivers of noncommunicable diseases; all focused on sociodemographic factors or circumstances of daily living. Nevertheless, the resulting actions to address social determinants ranged from individual-level interventions to population-wide measures and introducing representation of primary care organizations on system-level policy and planning committees.

CONCLUSION

Our findings may help policy-makers to consider suitable approaches for assessing and addressing social determinants of health in their domestic context. More rigorous observational and experimental evidence is needed to ascertain whether measuring social determinants leads to interventions which mitigate unmet social needs and reduce health disparities.

Embracing the complexity of modifiable risk reduction: A registry of modifiable risks for 0-12 month infants

Despite relatively high medical expenditures, the United States performs poorly on population health indicators relative to many other countries. A key step in addressing this situation involves determining impactful and cost-effective interventions for at-risk populations. This requires an understanding of medical, social, behavioral health and safety domains of risk. Of immediate interest are those risks that are modifiable at the individual and family levels and could be reduced through intervention and broader care coordination efforts. Unfortunately, a comprehensive list of such risks does not exist in the published literature. Using multiple interrelated methods, including clinical, social, and care coordination experience, expert elaboration and validation, and reviews of existing assessments and literature, we present what we believe to be the most comprehensive listing of individually modifiable risk factors (IMRFs), relevant to care coordination, available for individuals aged 0-12 months. The list addresses IMRFs within four broad domains of risk (medical, social, behavioral health, and safety). Comprehensive risk registries such as the one presented here can enhance our collective efforts to identify and mitigate risks for specific populations. Such registries can also support research to build understandings of the impact of risks, individually and in interconnected signature combinations. The risk registry presented here and the enhanced understandings flowing from it may yield useful insights for clinicians, social service providers and researchers seeking a whole person approach to care, as well as for payers and policymakers seeking to enable health policy and payment reforms to improve population health.