Social Determinants of Health Screening, Referral Best Practices

March 08, 2021 - Based on social determinants of health and health disparities alone, the number of people the US healthcare industry loses is comparable to seeing a 747 airplane crash out of the sky every day, according to Alisahah Cole, MD, system vice president of population health at CommonSpirit Health.

“Just think about that,” Cole encouraged her audience at Xtelligent Healthcare Media’s Patient Experience Summit.

“We do not tolerate if there's any kind of a quality issue within our airline industry, and we shouldn't, let me be really clear,” she said. “But why do we not have that same level of accountability, if you will, or same level of intolerance for clinical care variation that happens in the healthcare delivery system?”

By now, the topic of social determinants of health and the health equity issues that can stem from them is commonplace. The rise in value-based care contracts have given financial imperative to combat the social issues that impact an individual’s ability to achieve and maintain health and wellness.

And that’s not to mention the moral imperative Cole presented. Clinical care interventions only comprise about 20 percent of an individual’s overall health status, while the rest shakes out to things like physical environment, individual behavior that is largely in response to personal circumstance, and social determinants of health.

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In other words, there is a noteworthy portion of patient health and wellness that is, in fact, out of the control of the patient.

“There are decisions that we make, but there are also decisions being made for us that impact our health behaviors, and that actually ties into some of the social and economic factors and the physical environment,” Cole explained.

And ultimately, that can result in clinical differences, or health disparities. Take the social vulnerability index from the Centers for Disease Control & Prevention, Cole offered. This map ranks zip codes and looks at between 12 and 15 social determinants of health to combine them into an index score. The map, which CDC originally designed for disaster preparedness, can offer healthcare organizations a lot by way of understanding social determinants of health and outcomes.

At CommonSpirit, for example, Cole and her team were able to overlay the social vulnerability index with hotspots for certain chronic illnesses.

“If you look at rate of diabetes, if you look at rate of heart disease, obesity, if you look at unnecessary ED utilization, if you look at readmissions—guess what?” Cole queried. “You're likely going to see a correlation between having higher incidents or rates of those medical conditions or those utilization patterns in communities that have high social vulnerability index scores.”

And as healthcare faces the moral imperative to address those factors, the social determinants of health, it is essential organizations and individual clinicians do so in a patient-centered way.

For one thing, that means crafting a social determinants of health screening and referral system that is rooted in empathy. Clinicians should rid their vocabularies of phrases like “non-compliant” and dig to the root of patient care access and engagement barriers resulting in poor outcomes, Cole advised.

“I don't think people are non-compliant when it comes to their health,” she asserted. “I think they have barriers to achieving great health. The question is not about if a patient is non-compliant or if they are non-adherent, but why. What is happening to put those barriers up for that patient?”

And even that digging, that social determinants of health screening, needs to be patient-centered. After all, this type of population health and health equity work is new, and patients might not be used to this type of questioning during a visit. It takes a strong level of trust for patients to feel comfortable during a social determinants of health screening.

“When we really start thinking through how to start asking patients these questions, being thoughtful about the empathetic inquiry mindset, and knowing that even though we need to know this information, we recognize that although we need to know this information now to better take care of patients, this is new,” Cole explained. “This is not just new for our providers, but it's also new for the patients.”

For clinical practice and patient-provider communication, Cole recommended three guiding principles. Foremost, clinicians must tell patients that they are not required to complete a social determinants of health screening.

Next, clinicians must assure patients they don’t have to answer a particular question if they don’t want to. And relatedly, patients should know that they can stop the screening at any time. After all, social determinants of health are sensitive issues, and patients may not feel safe disclosing this type of information to their medical providers.

Part of patient-centricity is also having a centralized and efficient way of doing this. Healthcare is fragmented, often much to the detriment of patient experiences. At CommonSpirit, it has been important for clinicians to have an effective way of gathering social determinants of health data using the health system’s patient navigation technologies.

The tools, which utilize text message or video chat, are intended to help guide the patient through an episode of care. In the case of CommonSpirit’s initial rollout, that episode of care included pregnancy. Cole said the technology asked patients about certain risk factors, both clinical and non-clinical, and deployed community health workers to help guide patients through the non-clinical social determinants of health they may have reported.

CommonSpirit carries out a similar mission in its primary care clinics as part of its Total Health Roadmap program, which is funded by the Robert Wood Johnson Foundation. This program embeds community health workers right in the primary care team and office, making this type of health equity work a focal point in primary care.

“We integrate universal screening and referral for unmet social needs into the clinic workflow. However, it is the community health workers who are doing that screening and referral,” Cole explained.

“We have the community health workers who are embedded, their home base if you will, is the family medicine office. But then they're able to leave the office and go and check on patients and help patients get their medications if that's an issue or get food if that's an issue.”

Success in these programs hinges on community health partners and social services providers being able to close the loop, Cole added, and it is incumbent upon healthcare providers to be a part of that.

There are a number of closed-loop social services referral systems on the market, many of which can embed directly into the EHR. This prevents clinicians from detecting a social determinant of health without having a resource for referral, Cole said.

It has also helped provide a lot of support for the social service with whom a medical organization partners. For one thing, it helps clinicians and social services providers coordinate care for individuals.

“Then that community-based organization can receive the referral and then connect with the patient and then send information back to me as a family medicine doctor if I made the referral to say, ‘Hey, thank you for the referral. We were able to connect with Mr. Jones and was able to provide services,’” Cole explained. “It's kind of a closed loop referral, and that has been really, really helpful.”

Additionally, integrated social determinants screening and referral systems help social services groups know where they need to bulk up resources. If a housing intervention group sees a clinician is yielding high positivity rates for housing insecurity, it will know it needs to draw more resources.

This speaks to healthcare’s role in convening these types of resources. It is no secret that medicine is highly fragmented, as are all of the non-clinical resources individuals need to achieve wellness. Healthcare’s space in this journey is to be a neutral convener of these resources, helping to ultimately improve outcomes.

While this work holds the promise of a return in investment in value-based care models, much of this boils down a moral imperative, Cole reiterated. After all, much of health is the physical environment in which individuals live and their healthy behaviors. These are choices that are often made for patients, Cole asserted, and it is important for healthcare to therefore create equitable opportunity for health and wellness.

“We have to recognize that there are systems in place in this country that have excluded certain portions of the population. That could be based on race, ethnicity, social economics, sexual orientation, whether someone has a disability,” she concluded.

“We just have to recognize that those are all contributing factors of health inequities, and the default of our system is to continue to systematically exclude people. This is not about individuals being racist or being sexist, it really is how do we continue to intentionally consistently fight against these default systems?”

To learn more about social determinants of health intervention strategies and hear from more patient experience experts, check out our library of on-demand Patient Experience Virtual Summit content.