Reporting social determinants of health (SDOH) data has become the new norm for many care settings after a government mandate took effect earlier this year.
All healthcare organizations that admit patients are required to screen for five social risk drivers in accordance with a Centers for Medicare and Medicaid Services (CMS) regulation that took effect on Jan. 1, 2024. The required five SDOH domains are: food insecurity; interpersonal safety; housing insecurity; transportation insecurity; and utilities.
Primary care settings are also increasingly integrating screening methods for SDOH in response to emerging evidence that addressing social needs within a primary care setting can improve patient health.
Executing screening and referral processes, however, can come with obstacles, particularly for primary care settings. AHIMA spoke with Rachel Gold, PhD, MPH, about the barriers and strategies associated with screening and referral efforts in primary care settings. Gold is senior investigator for Kaiser Permanente Center for Health Research and director of implementation science programs for the non-profit organization OCHIN.
Q: What are some primary challenges that arise for care settings when implementing screening for SDOH?
A: An overarching challenge is that this screening can feel like a big change. For care settings where they've never done this screening before, it's asking people to rethink what their work means and how to do it. You've also got to figure out the workflow for doing the screening and ask questions like: How are you going to do it? Is it going to be the front desk person? Are you going to screen the patient ahead of time by text or through the patient portal?
There are also many different social risk screening tools out there that are at different levels of being validated. Some of them are 20 questions long. Some tools are three questions long. What's the right one to use? Do you want to screen people for everything, even though you're not using all that information? Do you want to just screen for the one that you can help with? These are all decisions that have to be made.
Q: What about obstacles when it comes to referrals?
A: That is a whole other can of worms. Some care organizations might have community-based social service organizations that they have good relationships with that they send patients to if they need certain services. But many don't have these relationships yet. On top of that, in a lot of cases, these social service agencies are not stable. Their funding may run out. You don't want to refer people to someplace that isn't there anymore. Also, some are only accessible to certain patients. For example, homeless shelters that only take women or they won't take felons. You need to be careful you don't refer a patient to someplace they can't actually go.
Q: What about some pathways to overcoming these barriers?
A: First and foremost, you have to have clinic leadership that is willing to do the work to implement this change. For clinics that are trying to implement a practice like this, as with any new practice, you could work with an outside facilitator who helps with the process. Often, they'll use small tests of change like plan, do, study, act (PDSA) cycles. It’s a way for clinics to try out a new process on a small scale, learn, and then expand and improve until they've got a system that works.
Now, a place like Kaiser Permanente, for example, can use their electronic health record system to automate the process of social risk screening, but not everyone has that capacity. We have created a guide to implementing social risk screening and referral-making to help clinics with the process. We encourage folks to check it out.
Q: Are there some best practices associated with SDOH implementation?
A: The best practice is engaging patients and staff and clinical leadership, and if you want to achieve referrals, also engaging community organizations in your planning process to figure out what's going to work in your community. There is no ‘one size fits all’ approach for this because communities are different. But the best practice is a careful, engaged planning process.
There are certainly individual clinics that have really figured out how to do this well. They have prioritized this effort, had clinic leadership support it, and they took the time to figure out how to do it in a way that works for their staff and patients.
Q: How important is buy-in from leadership?
A: It’s essential. One of the things we say in our guide is, you have to define why you are doing this. To get staff and clinic leadership buy-in, they have to understand how important it is and why it's going to make a difference for your patient.
But that's only part of it. There is also patient buy-in. Patients have every right to say, “I don't want to answer these questions,” and that's just fine. But you have to communicate with patients why you’re asking these questions because patient buy-in is critical as well.
Q: How can health information professionals help with buy-in?
A: They can use the data to make the case for why screening is important. For example, let’s say the data show that 20 percent of our patient population is food insecure, among those we’ve screened. That makes an argument for why we need to screen more systematically. Or you might use the data to show that your patients with food insecurity have worse diabetes outcomes. There's plenty of evidence out there about the importance of screening for SDOH, but people sometimes like to see it from their own organizations.
Q: What can you tell us about the current evidence on strategies for decreasing the health impacts of social risk?
A: We do have some evidence that shows that when patients get connected with social services, there are improved health outcomes in some cases. But this impact is not clear across the board. One area where there's pretty clear evidence is that just making a referral, giving the patient information, doesn't usually do much. You often need to support patients in accessing the services. We call that having a navigator. We're about to start a study to look at the impact of community health workers and what happens if you have a community health worker take on all of the social risk activities from screening to navigation.
These are folks who are from the community who work for the clinic, who are of the same background as the clinic patients. Having that person to connect with the patient may make a difference.
Q: What do you think the future holds for SDOH screening and referrals?
A: I am worried that if we increasingly have policies that ask clinics to do this screening without giving them the support to implement it effectively, that policymakers are going to conclude it doesn't work. But that is not accurate. The effort doesn't work unless you support it adequately.
I hope that screening for social risk becomes a standard part of care, and so commonplace that everyone expects [the assessments]. Then as we have more data on it, we get better and better at figuring out how to intervene effectively, and then we have policies that are then driven by this data. That's my hope.
Alicia Gallegos is a freelance healthcare reporter based in the Midwest.
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