‘A burgeoning field:’ How clinicians are addressing their patients’ growing social needs

Key takeaways:

• Clinicians should understand what SDOH are prevalent in their communities.
• There are several screening tools that can help identify adverse SDOH.
• Solutions to adverse SDOH should be local, one expert said.

Building community partnerships, having community specialists within a care team and using screening tools are all necessary steps to identifying and addressing social needs, according to experts.

Previous research has shown that adverse social determinants of health (SDOH) can lead to negative health outcomes such as higher odds of ED use and CVD mortality.

Efforts to address SDOH in clinical settings “is a relatively burgeoning field,” Mary Catherine E. Arbour, MD, MPH, an assistant professor of medicine at Harvard Medical School and medical director of the social care team at Brigham and Women’s Hospital’s Primary Care Center, told Healio. “In the last 10 years, we've learned a ton about how to do this work.”

Arbour and colleagues recently developed a primary care housing program, which involved hiring two community workers specializing in housing needs who worked with patients on finding shelter placement, housing applications, landlord or property management negotiations and other services. Findings showed that the program reduced primary care visits among participants and helped create stronger relationships between primary care providers and patients.

Enlarge  Resources suggested by Russell W. Kohl, MD, FAAFP.

Progress comes as adverse SDOH have continued to rise in the last half decade. According to the U.S. Department of Agriculture, the prevalence of food insecurity rose from 10.2% to 13.5% from 2021 to 2022. Additionally, a 2019 Kaiser Permanente survey showed that 68% of Americans had at least one unmet social need within the last year, whereas 21% prioritized food or rent over seeing a doctor or receiving medication.

As a result, primary care physicians must “be savvy at asking patients and identifying these needs and having appropriate counterparts, be they part of the office staff, part of the clinical team or community-based partners who can keep abreast of all of the changing social resources that are out there,” Arbour said.

Providers must understand SDOH domains, stigmas

Arbour explained that PCPs should understand what the prevalent domains of social need are among their patient population.

According to the HHS’ Healthy People 2030 initiative, there are five domains that SDOH can be grouped into:

• economic stability;
• education access and quality;
• social and community context;
• neighborhood and built environment (referring to physical spaces made for living, recreation and work); and
• health care access and quality.

Clinicians should also be aware that answering questions about social needs can be risky for the patient.

“For example, if I'm a mother of young children and I tell you that I have food insecurity, there may be a risk — or at least a stigma — and some shame associated with not being able to provide everything my children need,” Arbour noted. “Doctors need to be sensitive to the fact that someone who's disclosing this sort of information is in a vulnerable position.”

Importance of team-based care

Arbour noted that to effectively address social needs and risks, “there really needs to be other members of the care team who have expertise in connecting with patients around these needs and then accessing resources that are available or accessing community-based organizations that provide additional resources to patients.”

In Arbour’s care team, for example, there are community resource specialists who not only provide information about SDOH domains to patients but can help them navigate through the extensive process of getting the resources they need.

“If you've ever tried to navigate any kind of a public system, you'll know that there’s rooms of paperwork,” she explained. “It’s hard to know and do everything correctly to get through one of these processes, and our community health workers do an excellent job of helping patients overcome the typical barriers in a system — whether those barriers are due to convoluted processes, or whether those barriers are exacerbated by things like low literacy levels or language barriers.”

Screening tools, resource locaters are ‘critical’

Social needs, like diseases and other medical conditions, can be effectively identified using screening tools. Several major medical organizations offer SDOH-based screening tools, including:

• the National Association of Community Health Centers’ Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences tool, or PRAPARE;
• CMS’ Accountable Health Communities Health-Related Social Needs tool, or HRSN;
• Kaiser Permanente’s Your Current Life Situation survey, or YCLS; and the
• American Academy of Family Physicians’ (AAFP) social needs screening tool.

“I think it's really critical that folks use one of those tools,” Russell W. Kohl, MD, FAAFP, a family physician and speaker of the AAFP Congress of Delegates, told Healio. “That objective screening is what we don’t see in practice as much as perhaps our patients actually need.”

He explained that screenings can help to identify certain adverse SDOH that may not be immediately obvious to clinicians.

“One of the populations that [I’ve seen] a lot more of over the last year... is folks who are unhoused but are living in their cars and are working very hard to prevent anyone from figuring out that they're unhoused,” he said. “That's not somebody who, when they come into the office, is going to necessarily set off alarm bells for you... Having a screening tool to start is key, because your assumptions about people are not always going to be correct.”

Kohl also highlighted the AAFP’s free-to-use Neighbor Navigator tool, which allows providers to insert a zip code and receive a list of nearby programs for SDOH like food insecurity.

“That’s a great place to start because it can be overwhelming to a practice to say, ‘Oh my goodness, how do I come up with all of these [resources]?’” he said. “Having a go-to place that will give you the other people who are working on that and letting you connect [patients] to the resources that they need is the most important part.”

Addressing adverse SDOH in EDs

Like PCPs, emergency medicine physicians should understand what social care emergencies are, and which ones are “remediable,” Arbour said.

“If someone has nowhere to sleep tonight, that should activate emergency shelter,” she explained. “That isn't something that's accessible for everyone in our society, but it is something that should be pursued.”

She added that there are specific domains of need “where there is universal access and entitlement or protections in place, and I think that both PCPs and emergency physicians should be regularly updated and trained and refreshed on what those are.”

For example, for a patient who is facing housing insecurity and needs to access available resources, “they have to be documented as unhoused or homeless, and a doctor’s note that verifies that is helpful,” Arbour said.

Kohl also noted that emergency medicine physicians should think ahead and understand the factors that may bring a patient back into the ED.

“I think that what you'll find is a large portion of the things that drive people back to the ED aren't pathophysiology or a problem with the treatment,” he said. “It's the social environment that somebody goes back into that doesn't allow them to be successful.”

Local solutions

The kinds of community resources and tools that providers and health systems are missing can vary depending on their current level of investment and how much progress they have made in addressing SDOH so far.

“As health care delivery systems are trying to build approaches to identify and address SDOH, they’re doing it in all sorts of different ways,” Arbour explained. “We do nine domains. That’s big.”

In comparison, other health systems that are just starting to focus on adverse SDOH may choose a single domain on which to concentrate their efforts.

“For example, [Stanford Medicine Children’s Health] is starting with food insecurity, and they're starting with food insecurity because they have a single food bank that they have a partnership with,” Arbour noted. “They were able to build a direct referral within the electronic health record for anyone who screened positive for food insecurity, and that will connect them directly to a source of food, which is great.”

Arbour stressed that the problems that patients are facing that require community resources in the first place must have local solutions.

“When I have a patient who screens positive for some social need, having somebody from Timbuktu call my patient to talk about something that was found on an online database is less likely to help that patient find and access a high-quality resource than the system we’ve built, which is a system of tiered support with local people who know the local resource,” she explained.

Arbor also emphasized the importance of being a good partner to resources and programs.

“We have to be willing and ready to listen to our community partners,” she said.

Ultimately, physicians should strive to identify patients with adverse SDOH, even amid a busy work schedule, Kohl said.

“It's easy to think, ‘I'll have a social worker deal with this, or I'll have somebody else do it.’ But to be effective as a physician, you've got to have that relationship with the patient and be able to identify [the problem],” he said. “We may not be able to solve the problems. But the fact is that we can identify it, we can call it out, and we can connect you with resources — [it] is the same that we do for any other disease process.”

References:

• Americans see unmet needs in housing, food, social connection as a growing concern and significant barrier to health. https://www.prnewswire.com/news-releases/americans-see-unmet-needs-in-housing-food-social-connection-as-a-growing-concern-and-significant-barrier-to-health-300861235.html. Published June 4, 2019. Accessed March 27, 2024.
• Are you going hungry? Pediatricians are adding food insecurity to their health checks. https://stanmed.stanford.edu/tackling-social-challenges-good-health/#food. Accessed April 2, 2024.
• Frequently asked questions about screening for food insecurity. https://healthier.stanfordchildrens.org/en/frequently-asked-questions-about-screening-for-food-insecurity/. Published Feb. 3, 2023. Accessed April 2, 2024.
• Key statistics & graphics. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/key-statistics-graphics/. Accessed March 27, 2024.
• Neighborhood navigator. https://www.aafp.org/family-physician/patient-care/the-everyone-project/neighborhood-navigator.html. Accessed March 26, 2024.
• Social determinants of health. https://health.gov/healthypeople/priority-areas/social-determinants-health. Accessed March 26, 2024.
• The PRAPARE screening tool. https://prapare.org/the-prapare-screening-tool/. Accessed March 26, 2024.
• Three tools for screening for social determinants of health. https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/social_determinants.html. Accessed March 26, 2024.
• Your current life situation survey. https://sirenetwork.ucsf.edu/tools-resources/resources/your-current-life-situation-survey. Accessed March 26, 2024.