Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges

Abstract

Background Despite the importance of social determinants in health outcomes, little is known about the best practices for screening and referral during clinical encounters. This study aimed to implement universal social needs screening and community service referrals in an academic emergency department (ED), evaluating for feasibility, reach, and stakeholder perspectives. Methods Between January 2019 and February 2020, ED registration staff screened patients for social needs using a 10-item, low-literacy, English-Spanish screener on touchscreens that generated automatic referrals to community service outreach specialists and data linkages. The RE-AIM framework, specifically the constructs of reach and adoption, guided the evaluation. Reach was estimated through a number of approaches, completed screenings, and receipt of community service referrals. Adoption was addressed qualitatively via content analysis and qualitative coding techniques from (1) meetings, clinical interactions, and semi-structured interviews with ED staff and (2) an iterative “engagement studio” with an advisory group composed of ED patients representing diverse communities. Results Overall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). Forty-seven percent of patients with completed screeners communicated one or more needs, 34% of whom agreed to follow-up by resource specialists. Of the 482 participants referred, 20% were reached by outreach specialists and referred to community agencies. Only 7% of patients completed the full process from screening to community service referral; older, male, non-White, and Hispanic patients were more likely to complete the referral process. Iterative staff (n = 8) observations and interviews demonstrated that, despite instruction for universal screening, patient presentation (e.g., appearance, insurance status) drove screening decisions. The staff communicated discomfort with, and questioned the usefulness of, screening. Patients (n = 10) communicated a desire for improved understanding of their unmet needs, but had concerns about stigmatization and privacy, and communicated how receptivity of screenings and outreach are influenced by the perceived sincerity of screening staff. Conclusions Despite the limited time and technical barriers, few patients with social needs ultimately received service referrals. Perspectives of staff and patients suggest that social needs screening during clinical encounters should incorporate structure for facilitating patient-staff relatedness and competence, and address patient vulnerability by ensuring universal, private screenings with clear intent. Trial registration ClinicalTrials.gov, NCT04630041.

Implementing Health Related Social Needs Screening in an Outpatient Clinic

“…Focus on implementation strategies to address gaps in reach and adoption is needed. 15 - 17 ,33,34 Implementation science offers investigators frameworks through which the necessary implementation strategies and measures can be systematically identified to impact both screening uptake and patient capture. 15 , 35 , 36 …”

“…Studies that used the RE-AIM framework to examine HRSN screening implementation found screening was limited in its reach 15 , 16 and insured patients were more likely to undergo screening. 16 Our study found similar results.…”

“…To our knowledge, there is a dearth of peer-reviewed literature that examines implementation approaches for HRSN screening 15 - 17 in resource-constrained settings. Given these constraints, it is unknown if current outpatient HRSN screening processes capture a representative patient population, despite a push to universally screen.…”

Applying a Health Access Framework to Understand and Address Food Insecurity

“…However, it is unlikely that data collected through this mechanism will be representative of a community’s FI status as many of those who experience FI are also those experiencing barriers to accessing health services. Further, data suggest that the social stigma associated with FI and other social determinants may limit the ability to understand the problem during healthcare encounters, apply for federal programs, and seek information about available resources [ 48 , 49 ].…”

Pediatric emergency department organization and social care practices among U.S. fellowship programs

“…6,[13][14][15] Lessons learned from pediatric and adult emergency medicine social care networks suggest that effective and sustainable strategies recognize these physician-level limitations in pursuit of organizational solutions. 3,[16][17][18][19][20] In the ED, these macrolevel interventions, or organizational factors, aim to operationalize social risk awareness and assistance by integrated workflow approaches, community referral databases, and leveraging social work services. 5,19 In this study, our purpose was to assess the association between health care organizational factors and PEM physician social care perception and practices among PEM PDs and fellows in the United States.…”