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

Abstract

BackgroundDespite the importance of social determinants in health outcomes, little is known about 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.MethodsBetween 01/2019-02/2020, ED registration staff screened patients for social needs using a 10-item, low literacy, English-Spanish screener on touchscreens that generated automatic referrals to a community service outreach specialists and data linkages. The RE-AIM framework guided evaluation. Reach was estimated through number of approaches, and completed screenings; effectiveness was estimated through 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.ResultsOverall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). 47% 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. Staff communicated discomfort with, and questioned the need for, screening. Patients (n=10) communicated 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 perceived sincerity of screening staff. ConclusionsDespite 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: NCT04630041