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

Abstract

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.

Association of Patient and System-Level Factors With Social Determinants of Health Screening

“…Overall, completion was moderate with 58.7% of screenings completed. This completion was similar to previous studies that found an overall completion of 58%25 and completion of individual questions that varied between 55 and 67% 22. The result was also higher than two studies that had completion below 50%11,24 These findings may mean that extensive implementation activities may not be necessary for health systems that can leverage existing EHR infrastructure and workflows.…”

“…This completion was similar to previous studies that found an overall completion of 58% 25 and completion of individual questions that varied between 55 and 67%. 22 The result was also higher than two studies that had completion below 50% 11,24 These findings may mean that extensive implementation activities may not be necessary for health systems that can leverage existing EHR infrastructure and workflows. This finding may be especially applicable to other health systems that use Epic, which is the most used EHR vendor in the US with a market share of 29%.…”

“…Other health systems or practices used different approaches. First, many efforts included piloting the screening tool among a subset of patients to identify and address workflow issues 8,11,13,19–22. Although the Mayo Clinic rollout did not use a pilot study, responsive adjustments were made such as sending additional information to desk staff.…”

IMAGINE: A Trial of Messaging Strategies for Social Needs Screening and Referral

“…Workflow issues are a well-documented impediment to implementing HRSN screening and referral, 13,26,27 and ideal workflows are a current area of research focus. 28 Another potential factor for the decline in response rates was that the care manager at Clinic 2 resigned at the beginning of Stage 3; other staff members managed the screening process but likely were not as familiar with it. Finally, staff from all clinics thought that verbally explaining that the screening was intended to facilitate resource referrals might make patients less likely to complete the form if they were uninterested in assistance and that having MAs distribute it separately from other paperwork might make responding to the screening form seem more optional.…”

Trends and Racial/Ethnic Differences in Health Care Spending Stratified by Gender among Adults with Arthritis in the United States 2011–2019

“…Future research is warranted to investigate the extent to which women-specific barriers may result in delayed care, which could allow symptoms to worsen and necessitate more intensive and costlier services. Within the clinical setting, the implementation of data collection instruments that can identify the unmet social needs of all adults with arthritis is an evidence-based strategy that has been used in primary care settings [ 43 , 44 ]. Screening for unmet social needs can inform the gathering of relevant resources that can address identified needs, such as barriers to timely healthcare utilization, and reduce health inequities experienced by women with arthritis.…”