Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers

Beyond ''Screen & Refer'': Understanding Families' Use of Resources for Health-Related Social Needs Identified via Primary Care

OBJECTIVE

As health-related social needs (HRSN) screening increases, attention to families' resource preferences lags. This study of a pediatric primary care intervention (DULCE) with reliable HRSN screening and resource connection explored whether resources adequately addressed families' needs and, when HRSN persisted, families' reasons for declining resources.

METHODS

This retrospective cohort, mixed-methods study analyzed data from 989 families that received care at seven pediatric clinics implementing DULCE in three states. DULCE screens for seven HRSN around the 1-month and 4-month well-child visits; we calculated the percent of initial and ongoing positive screens. For positive rescreens, we calculated the percent that had all eligible or wanted resources and that were interested in further resources. We also analyzed case notes, which elicited families' resource preferences, and explored demographic characteristics associated with ongoing HRSN.

RESULTS

Half of enrolled families (508 of 989) initially screened positive for HRSN; 124 families had positive rescreens; 26 expressed interest in further assistance. Most families with ongoing concrete supports needs accessed all eligible resources (60-100%); 20-58% had everything they wanted. Fewer families with ongoing maternal depression and intimate partner violence accessed all eligible resources (48% and 18%, respectively); most reported having all wanted resources (76% and 90%, respectively). Families declined resources due to lack of perceived need, the HRSN resolving, or families addressed HRSN themselves. White families were more likely to rescreen positive.

CONCLUSIONS

Pediatric medical homes must honor family-centered decision-making while empowering families to accept beneficial resources. Health care systems should advocate for resources that families need and want.

Looking to "Level the Field": A Qualitative Study of How Clinicians Operationalize Social Determinants in Critical Care

Rationale: Current critical care practice does not integrate social determinants of health (SDOH) in systematic or standardized ways. Routine assessment of SDOH in the intensive care unit (ICU) may improve clinical decision making, patient- and family-centered outcomes, and clinician well-being. Objective: Given that the appropriateness and feasibility of SDOH assessment in the ICU is unknown, we aimed to understand how ICU clinicians think about and use SDOH. Methods: We conducted semistructured interviews with clinicians focused on barriers to and facilitators of assessing SDOH during critical illness and perceptions of screening for SDOH in the ICU. We used chart-stimulated recall to assist clinicians in reflecting on how SDOH applied to and was used in patients' care. After deidentifying interviews, we analyzed transcripts guided by a thematic analysis approach using a combination of inductive and deductive coding, the latter framed within the Centers for Disease Control and Prevention SDOH Healthy People framework. Results: We completed interviews with 30 clinicians in a variety of professional roles. The majority of clinicians self-identified as men (n = 17; 56.7%) of White race (n = 25; 83.3%). Clinicians contextualize their use of SDOH within three frames of reference: 1) their own identity and experiences; 2) their relationships and communication with patients and caregivers; and 3) immediate structures of care around ICU patients, including clinician advocacy, care transitions, and readmission. Clinicians identified that discussing SDOH could allow them to recognize bias faced by their patients, elucidate drivers of critical illness, and navigate communication with patients' caregivers. Clinicians worried about ICU-specific factors impeding the discussion of SDOH, including time constraints and acuity, high stakes and emotions, and negative anticipatory emotions. Conclusions: Clinicians gather SDOH during critical illness both to understand their patients' stories and to provide individualized care, which may lead to better clinician satisfaction and patient- and family-centered care outcomes. Educational and operational efforts to increase SDOH assessment and use in critical care should also gather and integrate the perspectives of patients and caregivers regarding the collection and use of SDOH in the ICU.

Identifying Veterans with a Higher Risk of Social Needs Using Cluster Analysis

IMPORTANCE

Many social need screening to advance population health and reduce health disparities, but barriers to screening remain. Improved knowledge of patient populations at risk for social needs based on administrative data could facilitate more targeted practices, and by extension, feasible social need screening and referral efforts.

OBJECTIVE

To illustrate the use of cluster analysis to identify patient population segments at risk for social needs.

DESIGN

We used clustering analysis to identify population segments among Veterans (N=2010) who participated in a survey assessing nine social needs (food, housing, utility, financial, employment, social disconnection, legal, transportation, and neighborhood safety). Clusters were based on eight variables (age, race, gender, comorbidity, region, no-show rate, rurality, and VA priority group). We used weighted logistic regression to assess association of clusters with the risk of experiencing social needs.

PARTICIPANTS

National random sample of Veterans with and at risk for cardiovascular disease who responded to a mail survey (N=2010).

MAIN OUTCOMES AND MEASURES

Self-reported social needs defined as the risk of endorsing (1) each individual social need, (2) one or more needs, and (3) a higher total count of needs.

KEY RESULTS

From the clustering analysis process with sensitivity analysis, we identified a consistent population segment of Veterans. From regression modeling, we found that this cluster, with lower average age and higher proportions of women and racial minorities, was at higher risk of experiencing ≥ 1 unmet need (OR 1.74, CI 1.17-2.56). This cluster was also at a higher risk for several individual needs, especially utility needs (OR 3.78, CI 2.11-6.78).

CONCLUSIONS

The identification of characteristics associated with increased unmet social needs may provide opportunities for targeted screenings. As this cluster was also younger and had fewer comorbidities, they may be less likely to be identified as experiencing need through interactions with healthcare providers.

Clinician and Patient Perspectives on the Exchange of Sensitive Social Determinants of Health Information

Importance

Social determinant of health (SDOH) data are essential to individualized care and reducing health disparities. However, there is little standardization in the way that SDOH data are collected, and barriers to increasing the collection of such data exist at both the patient and clinician levels.

Objective

To evaluate clinician, patient, and care partner perspectives on the barriers to and facilitators of patients sharing SDOH information with their clinicians.

Design, Setting, and Participants

This qualitative study included clinicians, patients, and care partners across the United States. Focus groups were conducted between September 2022 and February 2023 to understand the experience of collecting, documenting, and exchanging SDOH data.

Main Outcomes and Measures

Rapid assessment procedures were used to analyze focus group transcripts, creating summaries, codes, and themes mapped directly to the project research questions.

Results

A total of 235 individuals participated, including 109 (46.4%) clinicians (60 [55.0%] male; 25 [22.9%] Asian, 2 [1.8%] Black, and 74 [67.9%] White) and 126 (53.6%) patients and care partners (45 [35.7%] male; 1 [0.8%] Asian, 48 [38.1%] Black, and 64 [50.8%] White). Clinicians and patients agreed that SDOH data are important for clinicians to know. Both clinicians and patients wanted a structured, standardized way to collect SDOH data in the future, accompanied by time for more in-depth discussion during the visit. However, they highlighted numerous issues that impact collecting these data, including beliefs about how the information will be used, the clinician-patient relationship, having enough of the right staff, time needed to collect SDOH information, and technology used to collect the data (eg, usability, standardization).

Conclusions and Relevance

This qualitative study of the experience of collecting, documenting, and exchanging SDOH data underscores the ongoing barriers to widespread adoption of uniform approaches to SDOH data documentation as well as factors that may help lower those barriers, such as trusting patient-clinician relationships, greater transparency in how the data will be used, and targeted resources. A multifaceted approach to addressing the concerns raised by clinicians, patients, and care partners is required to ensure that such data can be captured in a way that improves care and allows for progress toward an equitable health care system.

Caring for dementia caregivers: How well does social risk screening reflect unmet needs?

BACKGROUND

Unmet social and caregiving needs can make caregiving for a person with dementia more difficult. Although national policy encourages adoption of systematic screening for health-related social risks (HRSRs) in clinical settings, the accuracy of these risk-based screening tools for detecting unmet social needs is unknown.

METHODS

We used baseline data from dementia caregivers (N = 343) enrolled in a randomized controlled trial evaluating CommunityRx-Dementia, a social care intervention conducted on Chicago's South Side. We assessed caregivers' (1) unmet social and caregiving needs by querying need for 14 resource types and (2) HRSRs using the Center for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) screening tool. Using unmet social needs as the reference, we examined the sensitivity of the AHC tool to detect food, housing, and transportation needs. Analyses were stratified by gender.

RESULTS

Most caregivers were women (78%), non-Hispanic (96%), Black (81%), partnered (58%) and had an annual household income ≥$50K (64%). Unmet social and caregiving needs were similarly prevalent among women and men caregivers (87% had ≥1 need, 43% had ≥5 needs). HRSRs were also prevalent. The most common HRSR was lack of social support (45%). Housing instability, difficulty with utilities and having any HRSRs were significantly more prevalent among women (all p < 0.05). The AHC screener had low sensitivity for detecting unmet food (39%, 95% confidence interval [CI]: 27%-53%), housing (42%, 95% CI: 31%-53%), and transportation (22%, 95% CI: 14%-31%) needs. Sensitivity did not differ by gender for food (41% for women and 30% for men, p = 0.72) or housing (44% for women and 29% for men, p = 0.37) needs. For transportation needs, sensitivity was 27% for women versus 0% for men (p = 0.01).

CONCLUSIONS

Men and women caregivers have high rates of unmet social needs that are often missed by the CMS-recommended risk-based screening method. Findings indicate a role for need-based screening in implementing social care.

Cystic fibrosis foundation position paper: Redefining the CF care model

Specialized care is provided to people with cystic fibrosis (pwCF) by interdisciplinary teams nested within the CF Foundation's accredited care center network. This network allows for standardization of the care model, implementation of clinical care guidelines, efficient communication, and outcomes reporting. Recent developments have impacted this care model. Increased access to CFTR modulator therapies has improved overall health for many, although not all pwCF. The COVID-19 pandemic resulted in a rapid adoption of telemedicine and remote monitoring to ensure continuity of CF care. A collaboration of care providers, pwCF, and parent caregivers reevaluated key aspects of the current care model and considered potential modifications based on a widening range of needs. Available evidence was used to evaluate components of routine clinical practice and identify potential adaptations to care. The review included identification of patient characteristics warranting intensive monitoring, while embracing patient-centric care, and emphasizing the integration of telemedicine and at-home health technologies. Despite the changing landscape, the importance of the relationship between pwCF, their support system, and the care team was confirmed as a timeless and foundational aspect of the care model. Shared decision making, partnership, and coproduced care plans between pwCF and their CF care teams guide the best adaptations of the care model to support individual priorities and wellbeing. As health care advances and pwCF age, further research is needed to understand the impact of the care model on long-term health outcomes and to identify best practices that support pwCF to live longer healthier lives.

Using the RE-AIM and TDF frameworks to evaluate the implementation of a standardized cognitive assessment protocol in outpatient rehabilitation

BACKGROUND

Impairments in cognition significantly affect patient functioning and rehabilitation outcomes. Assessment is essential to identifying at-risk individuals and guiding care plans.

OBJECTIVE

A cognitive assessment protocol was implemented in occupational therapy (OT) and speech-language pathology (SLP) outpatient practice. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and Theoretical Domains Framework (TDF), this study (1) measured the reach and adoption of the cognitive assessment protocol and (2) explored determinants and strategies that may affect adoption.

DESIGN

Sequential mixed methods.

SETTING

Two outpatient rehabilitation clinics (A and B) within a health care network.

PARTICIPANTS

Medical records from 220 adult patients with neurologic diagnosis and 15 OT and SLP clinicians.

INTERVENTIONS

Cognitive assessment protocol.

MAIN OUTCOME MEASURE(S)

Reach of the assessment protocol across patient characteristics and adoption across clinical sites were measured quantitatively via retrospective electronic medical records review. Qualitative data on effectiveness and the implementation process were collected via clinician focus groups.

RESULTS

Protocol adoption rates were 71% and 54% at clinics A and B, respectively. Site B OT was more likely to be noncompliant with protocol adoption compared to Site A, when controlling for patient characteristics, (81% vs. 16%, respectively; odds ratio = 11.4, 95% confidence interval [3.36-38.64], p ≤ .001). Patient age was a significant factor for protocol reach; older age was associated with noncompliance of the SLP protocol adoption, p < .05. Both sites employed implementation strategies targeting the provider level (eg, education/training); Site A additionally included organization-level strategies (eg, leadership engagement). In the absence of organization-level strategies, OT and SLP clinicians at Site B identified barriers related to leadership support, resources, and workflow.

CONCLUSIONS

Standardized practice protocols are feasible to implement within the rehabilitation setting, though multilevel implementation strategies may be needed to promote adoption. Aligning practices with the needs, values and priorities of the organization, providers, and patients and families is imperative.

Unpacking patient perspectives on social needs screening: A mixed methods study in western Colorado primary care practices

OBJECTIVE

Explore factors influencing patient comfort with and perceived helpfulness of screening for health-related social needs.

METHODS

In a parallel secondary mixed-methods analysis of data from three primary care clinics, we used logistic regression to examine effects of practice- and patient-level factors on comfort with and perceived helpfulness of social needs screening. We applied narrative analysis to 20 patient interviews to further understand how patients' lived experiences influenced their perceptions of screening.

RESULTS

Among 511 patients, receiving an explanation about screening was associated with increased odds of comfort (OR 2.1, 95% CI [1.1-4.30]) and perceived helpfulness (OR 4.7 [2.8-7.8]). Those experiencing more needs were less likely to report comfort (3 + needs vs. 0: OR 0.2 [0.1-0.5]). Narratives elucidated how a history of stigmatizing experiences increased discomfort disclosing needs and captured how relationship quality with healthcare teams influenced perceptions of screening for patients with extensive needs.

CONCLUSION

Practice-level (screening explanation and therapeutic rapport) and patient-level factors (history and extent of needs) are key influences on comfort with and perceived helpfulness of screening.

PRACTICE IMPLICATIONS

Good communication about screening benefits all patients. Patients with extensive social needs may require additional sensitivity to their past experiences.

The Complex Relationship Between Social and Functional Needs in Frail Older Adults

Background

There has been a growing interest in integrating social and function-focused care into health care settings. Little is known about what older adults perceive as the needs that impact their lives, and the resources to address patients' social and functional needs often exist outside of traditional health care settings.

Methods

Our objective was to understand frail older adults' and community organizations' perspectives on what social and functional needs impact older adults' health, the support they receive, and how organizations and health systems could partner to address these needs. We conducted semi-structured interviews with patients and community-based organizations. Patients were aged 65 years or older, frail (electronic frailty index greater than 0.21), and at an increased geographic risk of unmet social needs (Area Deprivation Index greater than or equal to the 75th percentile). Staff were from organizations that provided social and/or functional resources to older adults. We used an inductive content analysis approach and the constant comparative method to analyze the data and identify themes.

Results

We interviewed 23 patients and 28 staff from 22 distinct organizations. We found that social, financial, and functional needs were common and highly intertwined among older adults with frailty, but the support they received at home, from their health care providers, and from community organizations was highly varied.

Limitations

Our sample was limited to participants from one county, so the results may not be generalizable to other areas. We only inter-viewed organizations and patients with frailty.

Conclusions

Health systems and community organizations have distinct areas of expertise, and purposeful collaboration between them could be important in addressing the needs of frail older adults.

Implementation of social needs screening for minoritized patients newly diagnosed with breast cancer: a mixed methods evaluation in a pragmatic patient navigation trial

BACKGROUND

Social needs inhibit receipt of timely medical care. Social needs screening is a vital part of comprehensive cancer care, and patient navigators are well-positioned to screen for and address social needs. This mixed methods project describes social needs screening implementation in a prospective pragmatic patient navigation intervention trial for minoritized women newly diagnosed with breast cancer.

METHODS

Translating Research Into Practice (TRIP) was conducted at five cancer care sites in Boston, MA from 2018 to 2022. The patient navigation intervention protocol included completion of a social needs screening survey covering 9 domains (e.g., food, transportation) within 90 days of intake. We estimated the proportion of patients who received a social needs screening within 90 days of navigation intake. A multivariable log binomial regression model estimated the adjusted rate ratios (aRR) and 95% confidence intervals (CI) of patient socio-demographic characteristics and screening delivery. Key informant interviews with navigators (n = 8) and patients (n = 21) assessed screening acceptability and factors that facilitate and impede implementation. Using a convergent, parallel mixed methods approach, findings from each data source were integrated to interpret study results.

RESULTS

Patients' (n = 588) mean age was 59 (SD = 13); 45% were non-Hispanic Black and 27% were Hispanic. Sixty-nine percent of patients in the navigators' caseloads received social needs screening. Patients of non-Hispanic Black race/ethnicity (aRR = 1.25; 95% CI = 1.06-1.48) and those with Medicare insurance (aRR = 1.13; 95% CI = 1.04-1.23) were more likely to be screened. Screening was universally acceptable to navigators and generally acceptable to patients. Systems-based supports for improving implementation were identified.

CONCLUSIONS

Social needs screening was acceptable, yet with modest implementation. Continued systems-based efforts to integrate social needs screening in medical care are needed.

Spanish-Speaking Caregiver Preferences for Social Determinants of Health Screening

Equitable social determinants of health (SDOH) screening has been recommended by the Centers for Medicare & Medicaid Services and the Joint Commission; however, little is known about Spanish-speaking caregiver preferences on how they would like to be screened. We conducted a cross-sectional study at 3 pediatric clinics (October-December 2019). Caregivers completed (in English or Spanish) an SDOH screening preferences survey. Three hundred eighty-two of 443 caregivers approached (response rate = 86.2%) completed the survey. Most were female, preferred Spanish, and completed only high school. Spanish-speaking caregivers had greater odds of preferring verbal SDOH screening (odds ratio: 4.1; 95% confidence interval, 1.8-9.2) than English-speaking caregivers. Verbal SDOH screening should be a consideration in families who speak Spanish. Future studies should utilize qualitative methods to further explore Spanish-speaking caregiver preferences for SDOH screening.

Acceptance of Automated Social Risk Scoring in the Emergency Department: Clinician, Staff, and Patient Perspectives

Introduction

Healthcare organizations are under increasing pressure from policymakers, payers, and advocates to screen for and address patients' health-related social needs (HRSN). The emergency department (ED) presents several challenges to HRSN screening, and patients are frequently not screened for HRSNs. Predictive modeling using machine learning and artificial intelligence, approaches may address some pragmatic HRSN screening challenges in the ED. Because predictive modeling represents a substantial change from current approaches, in this study we explored the acceptability of HRSN predictive modeling in the ED.

Methods

Emergency clinicians, ED staff, and patient perspectives on the acceptability and usage of predictive modeling for HRSNs in the ED were obtained through in-depth semi-structured interviews (eight per group, total 24). All participants practiced at or had received care from an urban, Midwest, safety-net hospital system. We analyzed interview transcripts using a modified thematic analysis approach with consensus coding.

Results

Emergency clinicians, ED staff, and patients agreed that HRSN predictive modeling must lead to actionable responses and positive patient outcomes. Opinions about using predictive modeling results to initiate automatic referrals to HRSN services were mixed. Emergency clinicians and staff wanted transparency on data inputs and usage, demanded high performance, and expressed concern for unforeseen consequences. While accepting, patients were concerned that prediction models can miss individuals who required services and might perpetuate biases.

Conclusion

Emergency clinicians, ED staff, and patients expressed mostly positive views about using predictive modeling for HRSNs. Yet, clinicians, staff, and patients listed several contingent factors impacting the acceptance and implementation of HRSN prediction models in the ED.

Effects of the COVID-19 Pandemic on Patient Navigation for Health-Related Social Needs: Reflections From the Accountable Health Communities Model

BACKGROUND AND OBJECTIVES

This paper uses data from the Center for Medicare & Medicaid Innovation's Accountable Health Communities (AHC) Model to assess the effects of the COVID-19 pandemic on patient navigation (PN) for health-related social needs.

METHODS

We analyzed evaluation data from 28 organizations implementing the Center for Medicare & Medicaid Innovation's AHC Model. We first distilled themes from 81 stakeholder interviews conducted in 2021. We then analyzed quantitative beneficiary-level data on acceptance of navigation among 133,173 unique Medicare and Medicaid beneficiaries who were eligible for navigation between January 2019 and March 2021.

RESULTS

During the pandemic, interview participants described greater complexity of patients' cases and uncertainty regarding community service availability. Changes to navigation staffing and mode led to improvements in navigation quality and efficiency, but also challenges such as reduced rapport with patients. The pandemic increased navigator stress and burnout but also deepened appreciation for navigation among navigators and their patients. Beneficiaries were more likely to accept navigation during the pandemic than before the pandemic ( P < .05).

CONCLUSIONS

Changes in PN during the pandemic were perceived as both good and bad. Future work is needed to assess the long-term implications of pandemic-related changes to navigation for patients and navigators.

Screening tools for employment in clinical healthcare delivery systems: a content analysis

BACKGROUND

The relationship between work and health is complex and bidirectional, where work can have both health-harming and health-enhancing effects. Though employment is recognized as a social determinant of health, and clinical healthcare delivery systems are increasingly using screening tools to ask patients about social needs, little research has explored the extent to which employment-related social risk is captured in these screening tools. This study aimed to identify and characterize employment- and work-related questions in social risk screening tools that have been implemented in clinical healthcare delivery systems.

METHODS

We conducted a qualitative content analysis of employment-related items in screening tools that have been implemented in clinical healthcare service delivery systems. Three content areas guided data extraction and analysis: Setting, Domain, and Level of Contextualization.

RESULTS

Screening tools that asked employment-related questions were implemented in settings that were diverse in the populations served and the scope of care provided. The intent of employment-related items focused on four domains: Social Risk Factor, Social Need, Employment Exposure, and Legal Need. Most questions were found to have a low Level of Contextualization and were largely focused on identifying an individual's employment status.

CONCLUSIONS

Several existing screening tools include measures of employment-related social risk, but these items do not have a clear purpose and range widely depending on the setting in which they are implemented. In order to maximize the utility of these tools, clinical healthcare delivery systems should carefully consider what domain(s) they aim to capture and how they anticipate using the screening tools to address social determinants of health.

In-person versus electronic screening for social risks among carers of pediatric inpatients: A mixed methods randomized trial

We aimed to compare disclosure of social risks according to self-report on an iPad versus face-to-face questions from a health professional and to explore carers' experiences of screening. This two-arm, parallel group, randomized trial was conducted from January 19, 2021, to December 17, 2021, in a public hospital pediatric ward serving a disadvantaged area of an Australian capital city. Carers of children aged ≤ 5 years admitted to the Children's Ward were eligible. The primary outcome was disclosure of social risks. The screener included nine items on food security, household utilities, transport, employment, personal and neighborhood safety, social support, housing and homelessness. Disclosure of social risks was similar between the self-completion (n = 193) and assisted-completion (n = 193) groups for all 9 items, ranging 4.1% higher for worrying about money for food (95% CI - 11.4, 3.1%) among the assisted-completion group, to 5.7% (-1.6, 13.0%) higher for unemployment among the self-completion group. In qualitative interviews, participants were positive about screening for social risks in the hospital ward setting and the majority indicated a preference for self-completion.  Conclusion: Differences in the disclosure of social risks according to self- versus assisted-completion were small, suggesting that either method could be used. Most carers expressed a preference for self- completion, which is therefore recommended as the ideal mode for such data collection for Australian pediatric inpatient settings.  Trial registration: Australia New Zealand Clinical Trial Registry ( www.anzctry.org.au ; #ACTRN12620001326987; date of registration 8 December 2020). What is Known: • Most evidence on screening of social risks in pediatric inpatient settings is from the USA. • Little is known about disclosure of social risks in countries with universal health care and social welfare. What is New: • Disclosure of social risks was similar for electronic compared with face-to-face screening. • Carers preferred electronic completion over face-to-face completion.

Screening tools to address social determinants of health in the United States: A systematic review

The Centers for Medicare & Medicaid Services have mandated that hospitals implement measures to screen social determinants of health (SDoH). We sought to report on available SDoH screening tools. PubMed, Scopus, Web of Science, as well as the grey literature were searched (1980 to November 2023). The included studies were US-based, written in English, and examined a screening tool to assess SDoH. Thirty studies were included in the analytic cohort. The number of questions in any given SDoH assessment tool varied considerably and ranged from 5 to 50 (mean: 16.6). A total of 19 SDoH domains were examined. Housing (n = 23, 92%) and safety/violence (n = 21, 84%) were the domains assessed most frequently. Food/nutrition (n = 17, 68%), income/financial (n = 16, 64%), transportation (n = 15, 60%), family/social support (n = 14, 56%), utilities (n = 13, 52%), and education/literacy (n = 13, 52%) were also commonly included domains in most screening tools. Eighteen studies proposed specific interventions to address SDoH. SDoH screening tools are critical to identify various social needs and vulnerabilities to help develop interventions to address patient needs. Moreover, there is marked heterogeneity of SDoH screening tools, as well as the significant variability in the SDoH domains assessed by currently available screening tools.

Development of a comprehensive survey to assess key socioecological determinants of health

BACKGROUND

Although disparities in surgical outcomes are well-documented, our understanding of how socioecological factors drive these disparities remains limited. Comprehensive and efficient assessment tools are needed. This study's objective was to develop and assess the acceptability and feasibility of a comprehensive tool evaluating socioecological determinants of health in patients requiring colorectal surgery.

METHODS

In the first phase, a comprehensive socioecological determinant of health assessment tool was developed. A review of validated socioecological health evaluation instruments was conducted, and a 2-step modified Delphi method addressed the length, clarity, appropriateness, and redundancy of each instrument. A comprehensive tool was then finalized. In the second phase, the tool was tested for acceptability and feasibility in adult patients requiring colorectal surgery using a theory-guided framework at 3 Alabama hospitals. Relationships between survey responses and measures of acceptability and feasibility were evaluated using results from initial pilot tests of the survey.

RESULTS

In Phase 1, a modified Delphi process led to the development of a comprehensive tool that included 31 socioecological determinants of health (88 questions). Results of acceptability and feasibility were globally positive (>65%) for all domains. Overall, 83% of participants agreed that others would have no trouble completing the survey, 90.4% of respondents reported the survey was not burdensome, 97.6% of patients reported having enough time to complete the survey, and 80.9% agreed the survey was well-integrated into their appointment.

CONCLUSION

An 88-item assessment tool measuring 31 socioecological determinants of health was developed with high acceptability and feasibility for patients who required colorectal surgery. This work aids in the development of research needed to understand and address surgical disparities.

Menko S, Yazdani M, Vasan A, Scribano P, Shea JA, Kenyon CC. Parent Perspectives on Documentation and Sharing of Health-Related Social Needs Data

OBJECTIVE

Parents of pediatric patients are key stakeholders in the design and implementation of health-related social needs (HRSN) screening programs. Yet, there is little research exploring their perspectives on the documentation and sharing of HRSN data. We aimed to examine parents' preferences regarding how HRSN data are documented and shared.

METHODS

We conducted semi-structured interviews with parents of hospitalized children participating in an HRSN screening program at a quaternary care children's hospital. Interviews were coded using an inductive and deductive approach to identify emergent themes.

RESULTS

The 20 interviewed parents were uniformly female with 55% identifying as Black or African American and 20% identifying as Hispanic or Latino. Parents expressed comfort with electronic health record documentation of HRSN data and the use of International Classification of Diseases, 10th Revision Z codes as long as this information was used to provide families with meaningful support. Most parents viewed social workers and medical teams as the most appropriate recipients of HRSN data. Few parents felt comfortable with HRSN data being shared with payors. Parents desired transparency around HRSN data sharing. Many expressed concerns that documentation and sharing of HRSN data could lead to unwanted or unsafe disclosures or result in child welfare referrals.

CONCLUSIONS

Parents expressed comfort with HRSN documentation and sharing with health care providers, but requested that providers be transparent and respect parental preferences regarding data sharing to mitigate potential harms. When implementing HRSN support programs, health systems and payors should prioritize transparency around documentation and data sharing with families.

Caregiver Perceptions of Social Risk Screening in Pediatric Liver Transplantation: From the Multicenter SOCIAL-Tx Study

BACKGROUND

The social determinants of health contribute to adverse post-liver transplant outcomes. Identifying unmet social risks may enable transplant teams to improve long-term outcomes for at-risk children. However, providers may feel uncomfortable asking about household-level social risks in the posttransplant period because they might make their patients/families uncomfortable.

METHODS

We conducted a mixed-methods analysis of caregiver participants (ie, parents/guardians of pediatric liver transplant recipients) in the Social and Contextual Impact on Children Undergoing Liver Transplantation study to assess their perceptions of provider-based social risk screening. Participants (N = 109) completed a 20-min social determinants of health questionnaire that included questions on the acceptability of being asked intimate social risk questions. A subset of participants (N = 37) engaged in an in-depth qualitative interview to share their perceptions of social risk screening.

RESULTS

Of 109 participants across 9 US transplant centers, 60% reported financial strain and 30% reported at least 1 material economic hardship (eg, food insecurity, housing instability). Overall, 65% of respondents reported it very or somewhat appropriate and 25% reported being neutral to being screened for social risks in a liver transplant setting. In qualitative analyses, participants reported trust in the providers and a clear understanding of the intention of the screening as prerequisites for liver transplant teams to perform social risk screening.

CONCLUSIONS

Only a small minority of caregivers found social risk screening unacceptable. Pediatric liver transplant programs should implement routine social risk screening and prioritize the patient and family voices when establishing a screening program to ensure successful implementation.

Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations

BACKGROUND

Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs.

OBJECTIVE

To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs.

DESIGN

We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework.

PARTICIPANTS

Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted.

APPROACH

Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes.

KEY RESULTS

Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support.

CONCLUSIONS

VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

Health-related social needs information in the emergency department: clinician and patient perspectives on availability and use

BACKGROUND

Patient health-related social needs (HRSN) complicate care and drive poor outcomes in emergency department (ED) settings. This study sought to understand what HRSN information is available to ED physicians and staff, and how HRSN-related clinical actions may or may not align with patient expectations.

METHODS

We conducted a qualitative study using in-depth semi-structured interviews guided by HRSN literature, the 5 Rights of Clinical Decision Support (CDS) framework, and the Contextual Information Model. We asked ED providers, ED staff, and ED patients from one health system in the mid-Western United Stated about HRSN information availability during an ED encounter, HRSN data collection, and HRSN data use. Interviews were recorded, transcribed, and analyzed using modified thematic approach.

RESULTS

We conducted 24 interviews (8 per group: ED providers, ED staff, and ED patients) from December 2022 to May 2023. We identified three themes: (1) Availability: ED providers and staff reported that HRSNs information is inconsistently available. The availability of HRSN data is influenced by patient willingness to disclose it during an encounter. (2) Collection: ED providers and staff preferred and predominantly utilized direct conversation with patients to collect HRSNs, despite other methods being available to them (e.g., chart review, screening questionnaires). Patients' disclosure preferences were based on modality and team member. (3) Use: Patients wanted to be connected to relevant resources to address their HRSNs. Providers and staff altered clinical care to account for or accommodate HRSNs. System-level challenges (e.g., limited resources) limited provider and staff ability to address patients HRSNs.

CONCLUSIONS

In the ED, HRSNs information was inconsistently available, collected, or disclosed. Patients and ED providers and staff differed in their perspectives on how HSRNs should be collected and acted upon. Accounting for such difference in clinical and administrative decisions will be critical for patient acceptance and effective usage of HSRN information.

Food Insecurity Prevalence and Risk Factors at a Large Academic Medical Center in Michigan

Importance

Health care systems are increasingly adopting methods to screen for and integrate food insecurity and other social risk factors into electronic health records. However, there remain knowledge gaps regarding the cumulative burden of food insecurity in large clinical settings, which patients are most at risk, and the extent to which patients are interested in social assistance through their health care system.

Objective

To evaluate the 5-year prevalence and associated risk factors of food insecurity among adult primary care patients, and to examine factors associated with patients' interest in social assistance among those with food insecurity.

Design, Setting, and Participants

This cross-sectional analysis of a retrospective cohort study took place at a tertiary care academic medical center (encompassing 20 primary care clinics) in Michigan. Participants included adult patients who completed screening for social risk factors between August 1, 2017, and August 1, 2022. Data analysis was performed from November 2022 to June 2023.

Exposure

Food insecurity was assessed using the Hunger Vital Sign.

Main Outcomes and Measures

The primary outcome was patients' interest in social assistance, and associated factors were examined using multivariate logistic regression models, adjusting for patients' demographic and health characteristics.

Results

Over the 5-year period, 106 087 adult primary care patients (mean [SD] age, 52.9 [17.9] years; 61 343 women [57.8%]) completed the standardized social risk factors questionnaire and were included in the analysis. The overall prevalence of food insecurity was 4.2% (4498 patients), with monthly trends ranging from 1.5% (70 positive screens) in August 2018 to 5.0% (193 positive screens) in June 2022. Food insecurity was significantly higher among patients who were younger, female, non-Hispanic Black or Hispanic, unmarried or unpartnered, and with public health insurance. Food insecurity was significantly associated with a higher cumulative burden of social needs, including social isolation, medical care insecurity, medication nonadherence, housing instability, and lack of transportation. Only 20.6% of patients with food insecurity (927 patients) expressed interest in social assistance. Factors associated with interest in social assistance including being non-Hispanic Black, unmarried or unpartnered, a current smoker, and having a higher burden of other social needs.

Conclusions and Relevance

In this retrospective cohort study, the overall prevalence of food insecurity was 4.2%, of whom approximately 1 in 5 patients with food insecurity expressed interest in assistance. This study highlights ongoing challenges in ensuring all patients complete routine social determinants of health screening and gaps in patients' interest in assistance for food insecurity and other social needs through their health care system.

A Digital Intervention to Improve Skin Self-Examination Among Survivors of Melanoma: Protocol for a Type-1 Hybrid Effectiveness-Implementation Randomized Trial

BACKGROUND

Although melanoma survival rates have improved in recent years, survivors remain at risk of recurrence, second primary cancers, and keratinocyte carcinomas. The National Comprehensive Cancer Network recommends skin examinations by a physician every 3 to 12 months. Regular thorough skin self-examinations (SSEs) are recommended for survivors of melanoma to promote the detection of earlier-stage, thinner melanomas, which are associated with improved survival and lower treatment costs. Despite their importance, less than a quarter of survivors of melanoma engage in SSEs.

OBJECTIVE

Previously, our team developed and evaluated a web-based, fully automated intervention called mySmartSkin (MSS) that successfully improved SSE among survivors of melanoma. Enhancements were proposed to improve engagement with and outcomes of MSS. The purpose of this paper is to describe the rationale and methodology for a type-1 hybrid effectiveness-implementation randomized trial evaluating the enhanced MSS versus control and exploring implementation outcomes and contextual factors.

METHODS

This study will recruit from state cancer registries and social media 300 individuals diagnosed with cutaneous malignant melanoma between 3 months and 5 years after surgery who are currently cancer free. Participants will be randomly assigned to either enhanced MSS or a noninteractive educational web page. Surveys will be collected from both arms at baseline and at 3, 6, 12, and 18 months to assess measures of intervention engagement, barriers, self-efficacy, habit, and SSE. The primary outcome is thorough SSE. The secondary outcomes are the diagnosis of new or recurrent melanomas and sun protection practices.

RESULTS

Multilevel modeling will be used to examine whether there are significant differences in survivor outcomes between MSS and the noninteractive web page over time. Mixed methods will evaluate reach, adoption, implementation (including costs), and potential for maintenance of MSS, as well as contextual factors relevant to those outcomes and future scale-up.

CONCLUSIONS

This trial has the potential to improve outcomes in survivors of melanoma. If MSS is effective, the results could guide its implementation in oncology care and nonprofit organizations focused on skin cancers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/52689.

Toward standardization, harmonization, and integration of social determinants of health data: A Texas Clinical and Translational Science Award institutions collaboration

Introduction

The focus on social determinants of health (SDOH) and their impact on health outcomes is evident in U.S. federal actions by Centers for Medicare & Medicaid Services and Office of National Coordinator for Health Information Technology. The disproportionate impact of COVID-19 on minorities and communities of color heightened awareness of health inequities and the need for more robust SDOH data collection. Four Clinical and Translational Science Award (CTSA) hubs comprising the Texas Regional CTSA Consortium (TRCC) undertook an inventory to understand what contextual-level SDOH datasets are offered centrally and which individual-level SDOH are collected in structured fields in each electronic health record (EHR) system potentially for all patients.

Methods

Hub teams identified American Community Survey (ACS) datasets available via their enterprise data warehouses for research. Each hub's EHR analyst team identified structured fields available in their EHR for SDOH using a collection instrument based on a 2021 PCORnet survey and conducted an SDOH field completion rate analysis.

Results

One hub offered ACS datasets centrally. All hubs collected eleven SDOH elements in structured EHR fields. Two collected Homeless and Veteran statuses. Completeness at four hubs was 80%-98%: Ethnicity, Race; < 10%: Education, Financial Strain, Food Insecurity, Housing Security/Stability, Interpersonal Violence, Social Isolation, Stress, Transportation.

Conclusion

Completeness levels for SDOH data in EHR at TRCC hubs varied and were low for most measures. Multiple system-level discussions may be necessary to increase standardized SDOH EHR-based data collection and harmonization to drive effective value-based care, health disparities research, translational interventions, and evidence-based policy.

Engaging Emergency Nurses in Strategies to Address the Social Determinants of Health

INTRODUCTION

For patients with social needs, emergency departments can be an essential bridge between the health care system and the community. Emergency nurses' knowledge of and engagement in this work need to be examined to ensure that efforts for social determinants of health screening and the resulting community connections are effective. However, there is limited research in this area of nursing practice. The purpose of this study is to describe emergency nurses' knowledge about social needs in their community, assess their knowledge of existing community resources, and examine their perceived confidence to respond to the social needs of their patients.

METHODS

A cross-sectional survey was conducted with 243 nurses employed in a large regional health care system. Data were collected using an adapted 81-item social determinants of health survey instrument to measure knowledge of social determinants of health, confidence, and frequency of discussing social determinants of health with emergency department patients and awareness of social resources available in the community. Survey participants were asked about barriers to incorporating social determinants of health into their emergency department workflow and to provide general demographic information. Descriptive statistics were used to analyze study results.

RESULTS

Most of the 243 emergency nurse participants believed that addressing social determinants of health was important and that emergency nurses should be involved in issues around social determinants of health. However, most nurses reported limited knowledge about social determinants of health and had very limited knowledge about the resources available in their community to help patients with needs related to food, housing, medical care, and transportation. Nurses reported that although they know that their patients are unlikely to ask for help with social needs during an emergency department visit, they are still unlikely to ask their patients about social needs owing to low confidence about having social needs conversations, limited time, and competing care priorities. Participants advocated for greater case manager presence. Feeling connected to the community was significantly correlated to increased knowledge, confidence, and likelihood to ask about social needs (P < .05).

DISCUSSION

The emergency department is a logical place for screening for social determinants of health and connecting patients with social needs to community resources. Emergency nurses included in this study acknowledged that they want to address the social needs of their patients but reported that they lack knowledge about both social determinants of health and more importantly about the resources available to help patients with social needs. In general, they did not feel confident discussing social determinants of health with their patients in the emergency department and are unlikely to ask about social needs. Barriers to screening include time, competing care priorities, and lack of knowledge and support needed from case managers. Findings from this study have implications for supporting emergency nurses employed in institutions that seek to address social influences of health for the patients in their communities.

Screening for Financial Hardship: Comparing Patient Survey Responses Using Two Different Screening Tools

BACKGROUND

Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length.

OBJECTIVES

To compare two screening tools both containing questions related to financial hardship.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Convenience sample of adult patients (n = 471) in three primary care clinics.

MAIN MEASURES

Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health.

RESULTS

Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01).

CONCLUSIONS

Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

A survey of screening and support systems for socially high-risk pregnancies at obstetric facilities in Japan

AIM

To clarify the state of screening and support systems for socially high-risk pregnant women at obstetric facilities across Japan and identify the characteristics of facilities related to the implementation of screening.

METHODS

This cross-sectional study used a self-administered questionnaire. Participants were managers of hospitals, clinics, and midwifery birth centers handling deliveries in 47 prefectures across Japan. The questionnaire comprised items regarding the characteristics of participants and their facilities, service provision related to socially high-risk women available at the facility, the number of specified pregnant women (tokutei ninpu) per year, methods of screening, and support systems within the obstetric facilities. Descriptive statistics and multivariate logistic regression analysis were performed using IBM-SPSS version 24 for the association between facility characteristics and screening practices for socially high-risk pregnant women.

RESULTS

Valid responses were received from 716 of 2512 obstetric facilities. Rates of specified expectant mothers per annual number of deliveries were identified as follows: perinatal medical centers (2.7%), general hospitals (1.6%), obstetrics and gynecology hospitals (1.0%), and clinics (0.8%). A total of 426 facilities (60.6%) reported screening all expectant mothers to identify socially high-risk pregnant women. Multiple logistic regression analysis revealed that facility characteristics and service/care provision related to screening practices included availability of in-hospital midwife-led care and in-hospital midwifery clinics (adjusted odds ratio 1.61; 95% CI [1.30, 1.47]), one-on-one care by midwife (1.73; 95% CI [1.15, 2.59]), multidisciplinary meetings within the facility (1.70; 95% CI [1.14, 2.56]), follow-up support systems after discharge (1.90; 95% CI [1.17, 3.09]), and participation in the regional council for children in need of protection (2.33; 95% CI [1.13, 4.81]).

CONCLUSIONS

Approximately 60% of surveyed obstetric facilities screen for socially high-risk women. Increasing service provision at facilities may be necessary to implement screening.

Accuracy of a Single Financial Security Question to Screen for Social Needs

OBJECTIVES

Screening for social needs is recommended during clinical encounters but multi-item questionnaires can be burdensome. We evaluate if a single question about financial stress can be used to prescreen for food insecurity, housing instability, or transportation needs.

METHODS

We use retrospective medical record data from children (<11 years) seen at 45 primary pediatric care offices in 2022. Social needs screening was automated at well child visits and could be completed by the parent/guardian via the patient portal, tablet in the waiting room, or verbally with staff. We report the area under the receiver operating curve for the 5 response options of the financial stress question as well as sensitivity and specificity of the financial stress question ("not hard at all" vs any other response) to detect other reported social needs.

RESULTS

Of 137 261 eligible children, 130 414 (95.0%) had social needs data collected. Seventeen percent of respondents reported a housing, food, or transportation need. The sensitivity of the financial stress question was 0.788 for any one or more of the 3 other needs, 0.763 for food insecurity, 0.743 for housing instability, and 0.712 for transportation needs. Using the financial stress question as the first-step of a screening process would miss 9.7% of the families who reported food insecurity, 22.6% who reported housing instability, and 33.0% who reported transportation needs.

CONCLUSIONS

A single question screener about financial stress does not function well as a prescreen because of low sensitivity to reports of food insecurity, housing instability, and transportation needs.

Screening for Unstable Housing in a Healthcare Setting

Objectives: To describe existing tools for screening patients for unstable housing in a healthcare setting. Methods: A literature search was completed to retrieve articles published in the last 10 years on screening patients for unstable housing in a healthcare setting. Results: The current literature on screening patients for homelessness in healthcare settings describes a variety of tools administered by a range of healthcare providers, but all are based in the United States. Conclusion: The studies revealed the potential for effective screening in healthcare settings and positive engagement of patients and providers with screening. Key areas for future research include innovative methods of screening and evaluation of reliability and validity for a broader range of tools.

Patient Perspectives on Social Risk Screening and Documentation in a Dermatology Clinic

Importance

Providing person-centered dermatologic care includes consideration of social risk factors, such as housing instability and unreliable transportation, that may affect clinical management. Patients' perspectives on social risk screening and documentation in dermatology clinics have not yet been evaluated.

Objective

To understand patients' perspectives on social risk screening and documentation in a dermatology clinic.

Design, Setting, and Participants

This mixed-methods study used a survey and semistructured interviews and was conducted in a general dermatology clinic at a large urban public hospital. Patients at the clinic were eligible to complete the survey if they were 18 years or older; able to speak and read English, Spanish, or Cantonese; and comfortable using a computer tablet. Survey participants who preferred to use English were eligible for interviews. The survey included social risk screening questions, measures of acceptability, and questions on social risk factors associated with patient acceptability. Semistructured interviews were conducted to explore attitudes and beliefs about social risk screening and documentation. Survey and interview findings were integrated during data analysis through development of themes and joint display. Data were analyzed from December 2021 to April 2023.

Main Outcomes and Measures

There were 2 outcome measures of acceptability: appropriateness of screening in a dermatology clinic and comfort with documentation of social risk in the electronic health record (EHR).

Results

A total of 135 participants (including 73 males [54.1%]) answered both measures of acceptability in the survey. Of these participants, 116 (85.9%) reported that social risk screening in their dermatology clinic was very or somewhat appropriate and 85 (63.0%) reported being completely or somewhat comfortable with having their social risks documented in the EHR. Themes that were developed from surveys and interviews were the (1) role of interpersonal factors in willingness to disclose social risks, (2) implications of institutional trust for willingness to disclose and comfort with documentation, and (3) relevance of screening in a dermatology clinic.

Conclusions and Relevance

Results of this study showed that most participants found social risk screening to be appropriate in a dermatology clinic, although a smaller proportion of participants were comfortable with EHR documentation of their social risks. Optimizing patients' trust in their physicians and the medical system, while addressing privacy and discrimination concerns, may help facilitate disclosure of social risks.

Food Insecurity and Experiences of Discrimination Among Caregivers of Hospitalized Children

BACKGROUND AND OBJECTIVES

Pediatric hospitals are adopting strategies to address food insecurity (FI), a stigmatizing condition, among families with children. We hypothesized that parents and other caregivers ("caregivers") from households with FI or marginal food security (MFS) are more likely to experience discrimination during their child's hospitalization.

METHODS

We analyzed data from 319 caregivers of children admitted to an urban, academic children's hospital and randomly assigned to the control arm of the double-blind randomized controlled CommunityRx-Hunger trial (November 2020 to June 2022, NCT R01MD012630). Household food security in the 30 days before admission and discrimination during hospitalization were measured with the US Household Food Security Survey and the Discrimination in Medical Settings Scale, respectively. We used logistic regression to model the relationship between food security status and discrimination, adjusting for gender, race, ethnicity, income, and partner status.

RESULTS

Most participants were African American or Black (81.5%), female (94.7%), and the parent of the hospitalized child (93.7%). FI and MFS were prevalent (25.1% and 15.1%, respectively). Experiences of discrimination during a child's hospitalization were prevalent (51.9%). Caregivers with FI had higher odds than caregivers with food security of experiencing discrimination (adjusted odds ratio = 2.0, 95% confidence interval 1.1-3.6, P = .03); MFS was not significantly associated with discrimination (P = .25). Compared with food secure caregivers, those with FI had higher odds of 5 of 7 experiences of discrimination assessed.

CONCLUSIONS

Among parents and other caregivers, household FI is associated with experiences of discrimination during a child's hospitalization.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

A Qualitative Study of Perceptions and Preferences Regarding Social and Behavioral Risk Screening Among Primary Care Patients

BACKGROUND

Despite its relevance for healthcare settings, social and behavioral risk screening is not systematically performed by clinicians or healthcare systems.

OBJECTIVE

To address clinician concerns, such as social and behavioral risk screening disrupting the clinician-patient relationship and lack of resources to respond, we interviewed primary care patients at an academic medical center regarding their perceptions and preferences on social and behavioral risk screening.

PARTICIPANTS

Between September and December 2020, we recruited a convenience sample of 14 English-speaking primary care patients 18 years + from three clinics affiliated with an academic medical center.

APPROACH

Using a semi-structured interview guide, we asked about the importance of social and behavioral risk screening, whether or not and how to share social and behavioral risk factors, and how social and behavioral risk factors are addressed. We used a multi-step analytic process to identify the range and commonality of participants' responses thematically.

KEY RESULTS

Participants recognized that social and behavioral risk factor domains were relevant to primary care and important for treating the patient as a whole person. Participants preferred a conversation regarding social and behavioral risk factor with their primary care providers (PCPs), and suggested that, if surveys are used, they be followed with an open-ended, in-person discussion. Participants also suggested framing the discussion as something that is done routinely with all patients so that patients do not feel judged. Participants felt comfortable sharing social and behavioral risk factors when they trusted their PCPs, and felt that discussing social and behavioral risk factors with their PCPs built trust. Participants recognized that resources exist outside of the clinic, and suggested that PCPs distribute lists of relevant community resources to patients.

CONCLUSION

In our study of primary care patients on perceptions and preferences about screening and addressing social and behavioral risk factors, we found that patients were willing to share social and behavioral risk factors with their PCP, preferred an in-person discussions with or without a survey, and wanted a list of community resources to address their needs.

Patient comfort discussing sensitive behavioral health topics

BACKGROUND

: Following implementation of routine screening for depression in primary care, screening for other behavioral health issues is expanding. However, prior to implementing additional screening it is important to consider patient comfort answering sensitive questions related to behavioral health topics to determine screening acceptability and effectiveness.

METHODS

: A self-report survey was completed by U.S. adults over the age of 18 (n = 378) using Amazon Mechanical Turk. The survey assessed comfort discussing demographics, physical health, behavioral health, oral health, and living conditions with medical providers. Comfort levels of behavioral health topics were compared to comfort discussing depression symptoms and reasons for discomfort discussing topics were also surveyed.

RESULTS

: There were significant differences in comfort level discussing various behavioral health issues (F(8) = 51.70, P < .001). Participants reported being more comfortable discussing cigarette smoking and less comfortable discussing trauma, intimate partner violence (IPV) and gun ownership compared to depression. Privacy and perceived irrelevance were the most common reasons for discomfort.

CONCLUSIONS

: Accurate indices of patient behavioral health are essential for patient care. However, patients may be uncomfortable discussing some topics such as trauma, IPV, and gun ownership that patients view as private and/or unrelated to their treatment. Patient comfort may increase through provider trainings that focus on communication skills training, clear administrative procedures that allow for privacy and adequate time for discussions, and community education that underscores how these issues impact physical health.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study

OBJECTIVE

Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation.

METHODS

We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data.

RESULTS

Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data.

CONCLUSIONS

This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

Caregiver Perspectives on Social Needs Screening and Interventions in an Urban Children's Hospital

OBJECTIVES

Caregiver opinions of inpatient social needs screening and ways of addressing positive screens are not well understood. We aimed to explore caregiver perspectives and goals surrounding inpatient screening and determine how helpful provided resources are at meeting these goals.

METHODS

We conducted a qualitative study using semistructured interviews with caregivers of pediatric patients admitted to an urban tertiary care children's hospital from April to August 2021. English- and Spanish-speaking caregivers who screened positive for at least 1 social need on a standardized 10-item questionnaire were invited to participate in an interview 2 to 4 months after discharge. Interviews were recorded, transcribed, and analyzed by 2 independent coders using rapid qualitative methods.

RESULTS

We completed 20 interviews, with 14 English-speaking and 6 Spanish-speaking caregivers. Four themes emerged: (1) All caregivers expressed support for inpatient social needs screening. (2) Many caregivers cited it as an effective means to support families and help providers better understand their social situation. (3) Caregivers who recalled receiving a resource packet found it useful and at times even shared the resources with others. (4) The majority of caregivers expressed interest in longitudinal support, such as contact after discharge.

CONCLUSIONS

Caregivers are in support of inpatient screening as a means for providers to optimize comprehensive care that explores how unmet social needs influence health. Although inpatient social work and resource packets may be helpful, longitudinal support after discharge may improve the effectiveness of social needs interventions, patient outcomes, and caregiver satisfaction.

Addressing Social Determinants of Health in Practice

This review summarizes the current pediatric literature related to social determinants of health, including strengths and weaknesses of screening practices and intervention strategies, common concerns and potential unintended consequences, opportunities for further research, and provides evidence-informed practical strategies for clinicians.

Social Risk Screening and Response Equity: Assessment by Race, Ethnicity, and Language in Community Health Centers

INTRODUCTION

Little has previously been reported about the implementation of social risk screening across racial/ethnic/language groups. To address this knowledge gap, the associations between race/ethnicity/language, social risk screening, and patient-reported social risks were examined among adult patients at community health centers.

METHODS

Patient- and encounter-level data from 2016 to 2020 from 651 community health centers in 21 U.S. states were used; data were extracted from a shared Epic electronic health record and analyzed between December 2020 and February 2022. In adjusted logistic regression analyses stratified by language, robust sandwich variance SE estimators were applied with clustering on patient's primary care facility.

RESULTS

Social risk screening occurred at 30% of health centers; 11% of eligible adult patients were screened. Screening and reported needs varied significantly by race/ethnicity/language. Black Hispanic and Black non-Hispanic patients were approximately twice as likely to be screened, and Hispanic White patients were 28% less likely to be screened than non-Hispanic White patients. Hispanic Black patients were 87% less likely to report social risks than non-Hispanic White patients. Among patients who preferred a language other than English or Spanish, Black Hispanic patients were 90% less likely to report social needs than non-Hispanic White patients.

CONCLUSIONS

Social risk screening documentation and patient reports of social risks differed by race/ethnicity/language in community health centers. Although social care initiatives are intended to promote health equity, inequitable screening practices could inadvertently undermine this goal. Future implementation research should explore strategies for equitable screening and related interventions.

Non-response Bias in Social Risk Factor Screening Among Adult Emergency Department Patients

Healthcare organizations increasingly use screening questionnaires to assess patients' social factors, but non-response may contribute to selection bias. This study assessed differences between respondents and those refusing participation in a social factor screening. We used a cross-sectional approach with logistic regression models to measure the association between subject characteristics and social factor screening questionnaire participation. The study subjects were patients from a mid-western state safety-net hospital's emergency department. Subjects' inclusion criteria were: (1) ≥ 18 years old, (2) spoke English or Spanish, and (3) able to complete a self-administered questionnaire. We classified subjects that consented and answered the screening questionnaire in full as respondents. All others were non-respondents. Using natural language processing, we linked all subjects' participation status to demographic characteristics, clinical data, an area-level deprivation measure, and social risk factors extracted from clinical notes. We found that nearly 6 out of every 10 subjects approached (59.9%), consented, and completed the questionnaire. Subjects with prior documentation of financial insecurity were 22% less likely to respond to the screening questionnaire (marginal effect = -22.40; 95% confidence interval (CI) = -41.16, -3.63; p = 0.019). No other factors were significantly associated with response. This study uniquely contributes to the growing social determinants of health literature by confirming that selection bias may exist within social factor screening practices and research studies.

Screening Health-Related Social Needs in Hospitals: A Systematic Review of Health Care Professional and Patient Perspectives

Health outcomes are markedly influenced by health-related social needs (HRSN) such as food insecurity and housing instability. Under new Joint Commission requirements, hospitals have recently increased attention to HRSN to reduce health disparities. To evaluate prevailing attitudes and guide hospital efforts, the authors conducted a systematic review to describe patients' and health care providers' perceptions related to screening for and addressing patients' HRSN in US hospitals. Articles were identified through PubMed and by expert recommendations, and synthesized by relevance of findings and basic study characteristics. The review included 22 articles, which showed that most health care providers believed that unmet social needs impact health and that screening for HRSN should be a standard part of hospital care. Notable differences existed between perceived importance of HRSN and actual screening rates, however. Patients reported high receptiveness to screening in hospital encounters, but cautioned to avoid stigmatization and protect privacy when screening. Limited knowledge of resources available, lack of time, and lack of actual resources were the most frequently reported barriers to screening for HRSN. Hospital efforts to screen and address HRSN will likely be facilitated by stakeholders' positive perceptions, but common barriers to screening and referral will need to be addressed to effectively scale up efforts and impact health disparities.

The Social Determinants of Health and Their Impact on Dermatologic Health, Part 2: Taking Action to Address the Social Determinants of Health

The social determinants of health (SDoH) impact health and lead to health disparities in a variety of complex and intersecting ways. They are the nonmedical factors that must be addressed to improve health outcomes and achieve greater health equity. The SDoH contribute to dermatologic health disparities and decreasing these disparities requires multilevel action. Part 2 of this 2-part review offers a framework that dermatologists can use to help address the SDoH both at the point of care and in the health care system at large.

Perceived Appropriateness of Assessing for Health-related Socioeconomic Risks Among Adult Patients with Cancer

Cancer treatment can trigger or exacerbate health-related socioeconomic risks (HRSR; food/housing insecurity, transportation/utilities difficulties, and interpersonal violence). The American Cancer Society and National Cancer Institute recommend HRSR screening and referral, but little research has examined the perceptions of patients with cancer on the appropriateness of HRSR screening in healthcare settings. We examined whether HRSR status, desire for assistance with HRSRs, and sociodemographic and health care-related factors were associated with perceived appropriateness of HRSR screening in health care settings and comfort with HRSR documentation in electronic health records (EHR). A convenience sample of adult patients with cancer at two outpatient clinics completed self-administered surveys. We used χ 2 and Fisher exact tests to test for significant associations. The sample included 154 patients (72% female, 90% ages 45 years or older). Thirty-six percent reported ≥1 HRSRs and 27% desired assistance with HRSRs. Overall, 80% thought it was appropriate to assess for HRSRs in health care settings. The distributions of HRSR status and sociodemographic characteristics were similar among people who perceived screening to be appropriate and those who did not. Participants who perceived screening as appropriate were three times as likely to report prior experience with HRSR screening (31% vs. 10%, P = 0.01). Moreover, 60% felt comfortable having HRSRs documented in the EHR. Comfort with EHR documentation of HRSRs was significantly higher among patients desiring assistance with HRSRs (78%) compared with those who did not (53%, P < 0.01). While initiatives for HRSR screening are likely to be seen by patients with cancer as appropriate, concerns may remain over electronic documentation of HRSRs.

Significance

National organizations recommend addressing HRSRs such as food/housing insecurity, transportation/utilities difficulties, and interpersonal violence among patients with cancer. In our study, most patients with cancer perceived screening for HRSRs in clinical settings as appropriate. Meanwhile, concerns may remain over the documentation of HRSRs in EHRs.

The adoption of social determinants of health documentation in clinical settings

OBJECTIVE

To understand the frequency of social determinants of health (SDOH) diagnosis codes (Z-codes) within the electronic health record (EHR) for patients with prediabetes and diabetes and examine factors influencing the adoption of SDOH documentation in clinical care.

DATA SOURCES

EHR data and qualitative interviews with health care providers and stakeholders.

STUDY DESIGN

An explanatory sequential mixed methods design first examined the use of Z-codes within the EHR and qualitatively examined barriers to documenting SDOH. Data were integrated and interpreted using a joint display. This research was informed by the Framework for Dissemination and Utilization of Research for Health Care Policy and Practice.

DATA COLLECTION/EXTRACTION METHODS

We queried EHR data for patients with a hemoglobin A1c > 5.7 between October 1, 2015 and September 1, 2020 (n = 118,215) to examine the use of Z-codes and demographics and outcomes for patients with and without social needs. Semi-structured interviews were conducted with 23 participants (n = 15 health care providers; n = 7 billing and compliance stakeholders). The interview questions sought to understand how factors at the innovation-, individual-, organizational-, and environmental-level influence SDOH documentation. We used thematic analysis to analyze interview data.

PRINCIPAL FINDINGS

Patients with social needs were disproportionately older, female, Black, uninsured, living in low-income and high unemployment neighborhoods, and had a higher number of hospitalizations, obesity, prediabetes, and type 2 diabetes than those without a Z-code. Z-codes were not frequently used in the EHR (<1% of patients), and there was an overall lack of congruence between quantitative and qualitative results related to the prevalence of social needs. Providers faced barriers at multiple levels (e.g., individual-level: discomfort discussing social needs; organizational-level: limited time, competing priorities) for documenting SDOH and identified strategies to improve documentation.

CONCLUSIONS

Providers recognized the impact of SDOH on patient health and had positive perceptions of screening for and documenting social needs. Implementation strategies are needed to improve systematic documentation.

Unwanted sexual activity among United States women early in the COVID-19 pandemic

BACKGROUND

Female sexual activity and, accordingly, birth rates tend to decline in times of stress, such as a pandemic. In addition, when resources are scarce or exogenous conditions are threatening, some women may engage in sexual activity primarily to maintain socioeconomic security. Having unwanted sex may indicate sexual activity in exchange for economic security.

OBJECTIVE

This study aimed to describe patterns and correlates of unwanted sex, defined as having sex more frequently than desired, among US women early in the COVID-19 pandemic.

STUDY DESIGN

The National US Women's Health COVID-19 Study was conducted in April 2020, using a nested quota sample design to enroll 3200 English-speaking women (88% cooperation rate) aged 18 to 90 years recruited from a research panel. The quota strata ensured sufficient sample sizes in sociodemographic groups of interest, namely, racial and ethnic subgroups. Patterns of sexual activity, including unwanted sex early in the pandemic, were described. To further elucidate the experiences of women reporting unwanted sex, open-ended responses to an item querying "how the coronavirus pandemic is affecting your sex life" were assessed using conventional content analysis. Logistic regression analyses-adjusting for sociodemographic characteristics, self-reported health, and prepandemic health-related socioeconomic risk factors, including food insecurity, housing instability, utilities and transportation difficulties, and interpersonal violence-were used to model the odds of unwanted sex by a pandemic-related change in health-related socioeconomic risk factors.

RESULTS

The proportion of women who were sexually active early in the pandemic (51%) was about the same as in the 12 months before the pandemic (52%), although 7% of women became active, and 7% of women became inactive. Overall, 11% of sexually active women were having unwanted sex in the early pandemic. The rates of anxiety, depression, traumatic stress symptoms, and each of the 5 health-related socioeconomic risk factors assessed were about 2 times higher among women having unwanted sex than other women (P<.001). Women having unwanted sex were also 5 times more likely than other women to report an increased frequency of sex since the pandemic (65% vs 13%; P<.001) and 6 times more likely to be using emergency contraception (18% vs 3%; P<.001). Women reporting unwanted sex commonly described decreased libido or interest in sex related to mood changes since the pandemic, having "more sex," fear or worry about the transmission of the virus because of sex, and having sex to meet the partner's needs. Among sexually active women, the odds of unwanted sex (adjusting for demographic, reproductive, and health factors) were higher among women with 1 prepandemic health-related socioeconomic risk factor (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.8) and 2 or more prepandemic health-related socioeconomic risk factors (adjusted odds ratio, 6.0; 95% confidence interval, 3.4-10.6). Among sexually active women with any prepandemic health-related socioeconomic risk factor, those with new or worsening transportation difficulties early in the pandemic were particularly vulnerable to unwanted sex (adjusted odds ratio, 2.7; 95% confidence interval, 1.7-4.3).

CONCLUSION

More than 1 in 10 sexually active US women was having unwanted sex early in the COVID-19 pandemic. Socioeconomically vulnerable women, especially those with new or worsening transportation problems because of the pandemic, were more likely than others to engage in unwanted sex. Pandemic response and recovery efforts should seek to mitigate unwanted sexual activity and related health and social risks among women.

A Survey of the National Comprehensive Cancer Network on Approaches Toward Addressing Patients' Transportation Insecurity

BACKGROUND

Addressing patients' social determinants of health is a national priority for cancer treatment centers. Transportation insecurity is one major challenge for patients undergoing active cancer treatment, and missing treatments can result in worse cancer treatment outcomes, including worse morbidity and mortality. How cancer treatment centers are addressing transportation insecurity is understudied.

METHODS

In January and February 2022, the NCCN Best Practices Committee conducted a survey of NCCN's 31 Member Institutions (currently 32 member institutions as of April 2022) to assess how centers were addressing patient transportation insecurity: how they screen for transportation insecurity, coordinate transportation, and fund transportation initiatives, and their plans to address transportation insecurity in the future.

RESULTS

A total of 25 of 31 (81%) NCCN Member Institutions responded to the survey, of which 24 (96%) reported supporting the transportation needs of their patients through screening, coordinating, and/or funding transportation. Patients' transportation needs were most often identified by social workers (96%), clinicians (83%), or patients self-declaring their needs (79%). Few centers (33%) used routine screening approaches (eg, universal screening of social risk factors) to systematically identify transportation needs, and 54% used the support of technology platforms or a vendor to coordinate transportation. Transportation was predominantly funded via some combination of philanthropy (88%), grants (63%), internal dollars (63%), and reimbursement from insurance companies (58%). Over the next 12 months, many centers were either going to continue their current transportation programs in their current state (60%) or expand existing programs (32%).

CONCLUSIONS

Many NCCN Member Institutions are addressing the transportation needs of their patients. Current efforts are heterogeneous. Few centers have systematic, routine screening approaches, and funding relies on philanthropy more so than institutional dollars or reimbursement from insurers. Opportunities exist to establish more structured, scalable, and sustainable programs for patients' transportation needs.

Insights Into Patients' Perceptions of Health-Related Social Needs and the Role of the Adult Primary Care Clinic

INTRODUCTION/OBJECTIVES

While it is well established that unmet healthrelated social needs (HRSN) adversely affect health outcomes, there has been limited evaluation in adult primary care of patients' perceptions of how these needs impact their health and the role of the primary care provider (PCP). The objective of this study is to identify patients' perceptions of HRSN and how PCPs could help address them. Secondary objectives include exploring the impact of goal setting and a 1-time cash transfer (CT).

METHODS

This qualitative study used semi-structured baseline and follow-up interviews with patients in internal medicine clinics. Adult primary care patients were included if they screened positive as having 1 of 3 HRSN: financial resource strain, transportation needs, or food insecurity. All participants completed an initial interview about their HRSN and health, and were asked to set a 6-month health goal. At enrollment, participants were randomized to receive a $500 CT or a $50 participation reward. At 6-months, patients were interviewed again to investigate progress toward meeting their health goals, [when applicable] how the CT helped, and their beliefs about the role of PCPs in addressing HRSN.

RESULTS

We completed 30 initial and 25 follow-up interviews. Participants identified their HRSN, however most did not readily connect identified needs to health. Although participants were receptive to HRSN screening, they did not feel it was their PCP's responsibility to address these needs. Verbal goal-setting appeared to be a useful tool, and while the CTs were appreciated, patients often found them inadequate to address HRSN.

CONCLUSIONS

Given the importance of identifying the social conditions that shape patients' health, providers, and health systems have an opportunity to re-evaluate their role in helping patients address these barriers. Future studies could examine the effect of more frequent disbursement of CTs over time.