Patient Screening for Social Needs: Most Clinicians Aren’t Asking Enough Questions

When you see a patient in the hospital or an exam room, you’re only getting a small glimpse into their lives. You can’t see where they live, the conditions of their environment, the food they eat or many of the other factors that play into their health and well-being.

“While the care we receive plays an important role, health outcomes may often be driven by the conditions in which we live, learn, work, and play,” wrote Cara V. James, PhD, director of the Office of Minority Health for the Centers for Medicare & Medicaid Services (CMS) in a blog post earlier this year.

However, only a small minority of physician practices and hospitals are screening for all of a person’s key social needs, according to a new study for JAMA Network Open. The researchers noted that there is a lot of room for improvement.

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Determinants of health: What are clinicians missing?  

According to the World Health Organization and the U.S. Department of Health and Human Service’s Healthy People 2020 initiative, there are five factors that contribute to a person’s health:

  1. Biology and genetics
  2. Individual behavior
  3. Physical environment
  4. Social environment
  5. Health services, including access to care

Physicians, nurses and other medical staff fill out medical history forms every day that provide answers to the first two items on this list, and but far fewer are getting a complete picture of a patient’s environment, their access to important services and their ability to follow treatment plans.

CMS: The five key social needs

How is a clinician expected to know all the relevant information about a patient’s home life, and their social and physical needs?

They can take a cue from a screening tool developed by the CMS Center for Medicare and Medicaid Innovation (CMMI). The CMMI includes five key domains in the Health-Related Social Needs (HRSN) Screening Tool that it created for the Accountable Health Communities (AHC):

  1. Housing instability
  2. Food insecurity
  3. Transportation problems
  4. Utility help needs
  5. Interpersonal safety

Less than 1 in 4 are asking the right questions

Researchers asked hospitals and physician practices if they were screening for these five social needs in the new JAMA Network Open study, which was led by Taressa K. Fraze, PhD, with the Dartmouth Institute for Health Policy and Clinical Practice.

The results? Only 24.4 percent of the hospitals and 15.6 percent of physical practices surveyed were screening for all five of those factors. In fact, 33.3 percent of practices and 8 percent of hospitals reported that they didn’t do any screening for social needs at all.

The study participants noted that challenges arise when it comes to screening for social needs. Common obstacles include a lack of time, a lack of capacity for addressing any problems that are uncovered during screening, and a lack of financial resources to help patients solve those needs.

“This is really hard to do, and hospitals and practices are under a ton of pressure to do so many things during any clinical encounter,” noted Laura Beidler, MPH, research project coordinator at the Dartmouth Institute for Health Policy and Clinical Practice and a co-author of the new JAMA study.

An expanding array of resources and programs  

Need help gathering this vital information? A growing number of programs are taking up the cause—raising awareness of the importance of social determinants of health to populations, and looking for ways to address them.

The Centers for Disease Control and Prevention (CDC) has at least eight programs, many of which work together with community partners across a range of sectors. The American Academy of Pediatrics (AAP) offers resources on social determinants of health. And the American Academy of Family Physicians (AAFP) launched The EveryONE Project in 2018 as a resource to help family physicians better address social determinants of health for the patients in their practices, and in their communities.

Individual institutions are also creating new screening methods or programs in an effort to improve patient outcomes.

For example, Boston Medical Center recently published the results of an observational study in which a team of researchers gave a one-page screening tool to patients in primary care settings. The responses were entered into the patients’ electronic health record (EHR), and helped identify social needs like housing or food that might have otherwise gone undetected. The medical center is now using the tool, called THRIVE, with all patients in their ambulatory primary care centers.

Identifying vulnerable populations 

Clinicians should also be aware of especially vulnerable populations.

According to a new research letter, published September 30, 2019 in JAMA Internal Medicine, Medicare enrollees under age 65 reported significantly more food insecurity than Medicare enrollees over age 65.  Many of the first group are especially vulnerable due to factors such as long-term disabilities that qualified them for early Medicare enrollment, and many are also enrolled in Medicaid, noted researcher Jeanne Madden, PhD, associate professor in the Department of Pharmacy and Health Systems Sciences at Northeastern University.

“I think it’s important for physicians to know more about their patients than just about their physical state,” said Madden, adding that life circumstances like food insecurity can play a very important role in a patient’s treatment and overall health.

Just ask 

Even without a formal screening tool, clinicians and their staff can still gather important information from patients, just by asking a few questions along the lines of the CMS five key domains. They can then use that information to help shape an individual care plan that has greater chance of success.

“Having those conversations could be really helpful for a lot of those patients,” said Beidler.

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