Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study

Barriers and facilitators to screening for intimate partner violence at a level 1 trauma center

BACKGROUND

Intimate partner violence (IPV) is a significant public health problem that is associated with substantial health sequelae, including traumatic injury. Surgical professional societies recommend universal intimate partner violence screening in patients presenting after trauma, but this recommendation is not uniformly implemented. We designed and implemented a quality improvement project at our institution in July 2020 to enhance intimate partner violence screening. Although screening rates improved, they remained suboptimal. Therefore, we sought to examine barriers and facilitators to intimate partner violence screening from trauma clinicians' perspectives.

STUDY DESIGN

We conducted a qualitative study using in-depth, semistructured interviews to understand the perspectives and experiences of trauma clinicians conducting intimate partner violence screening. A constructivist paradigm informed our study whereby our data collection approaches aimed to understand intimate partner violence screening from the perspectives of those tasked with implementing screening within real-world clinical settings. We used thematic analysis to analyze our data and generate themes related to barriers and facilitators to screening.

RESULTS

We conducted interviews with 12 resident physicians and 2 advance practice providers. We identified 6 themes, 3 reflecting facilitator themes as (1) standardized education and workflow, (2) benefits of interdisciplinary teamwork, and (3) context of screening, and 3 reflecting barrier themes as (1) lack of time, (2) language misinterpretation, and (3) perceived inappropriateness of universal screening.

CONCLUSION

Trauma clinicians described multiple facilitators and barriers to screening for intimate partner violence following traumatic injury, some of which were unique to the trauma setting. Projects seeking to achieve universal screening following traumatic injury may benefit from accounting for these factors when designing interventions.

Impact of systematic screening for social determinants of health in a level IV neonatal intensive care unit

Objective

To determine whether screening for social determinants of health (SDoH) in a level IV neonatal intensive care unit (NICU) could uncover additional family needs.

Methods

Secondary analysis of a prospective study in a level IV NICU. Participants filled out the Protocol for Responding to and Assessing Patients' Assets, Risks and Experiences (PRAPARE) tool, which includes economic, housing, transportation, and safety questions. Questionnaires were completed via secure tablet; the research team notified social workers of reported needs. Illness and demographic characteristics were compared between families who did and did not report resource needs. Manual chart review assessed subsequent response to reported SDoH needs.

Results

Of 319 respondents, 61(19%) reported resource needs. Of 61 families, 88% received repeat social work encounter to re-assess for resources; 59% received new resource referrals.

Conclusions

Systematic SDoH screening can identify needs throughout the NICU stay, even among families already connected to social work support.

Opening Pandora's box - key facilitators of practice change in detecting and responding to childhood adversity - a practitioner perspective

BACKGROUND

Childhood adversities worsen physical and mental health across the lifespan. Health and social care practitioners play a key role in identifying and responding to childhood adversity, however, may be reluctant to do so due to a perceived lack of services to refer to, time pressures and a deficit of training and confidence. We aimed to (1) quantify changes in practitioner comfort and confidence to identify and respond to childhood adversity following a multimodal intervention within an integrated child and family health and social care hub and (2) to understand barriers and facilitators of practice change.

METHODS

Hub practitioners were surveyed about their competence and comfort to directly ask about and confidence to respond to adversity at baseline and then at six and twelve months post training. Interviews were undertaken to explore practitioner barriers and enablers of practice change. Interviews were recorded, transcribed verbatim, and analysed using reflexive thematic analysis. The theoretical domains framework was used to identify the key drivers of practice change.

RESULTS

Fifteen of 18 practitioners completed all three surveys and 70% reported increased competence and comfort to directly ask, and confidence to respond across a range of adversities over the 12-month intervention. Twenty-one practitioners completed interviews. Six themes were identified as either facilitators or barriers to practice change. Facilitator themes included (1) connection matters, (2) knowledge provides assurance, (3) confidence in ability and (4) choosing change. Barrier themes were (1) never enough time and (2) opening Pandora's box. Following analysis, key drivers of practice change were 'social influence', 'belief in capability', 'knowledge' and 'behaviour regulation' while barriers to practice change were 'environmental context and resources' and 'emotion'.

CONCLUSIONS

Practitioners reported improved confidence in identifying and responding to adversity through a multimodal intervention delivered in an integrated Child and Family Hub. Changing practice requires more than just education and training. Opportunities for social connection and coaching to improve self-confidence and perceived competence are needed to overcome the fear of opening Pandora's box.

The Association Between Hospital-Based Food Pantry Use and Subsequent Emergency Department Utilization Among Medicaid Patients With Diabetes

We explored the association between the use of a hospital-based food pantry and subsequent emergency department (ED) utilization among Medicaid patients with diabetes in a large safety-net health system. Leveraging 2015-2019 electronic health record data, we used a staggered difference-in-differences approach to measure changes in ED use before vs after food pantry use. Food pantry use was associated with a 7.3 percentage point decrease per patient per quarter (95% confidence interval, -13.8 to -0.8) in the probability of subsequent ED utilization ( P = .03). Addressing food insecurity through hospital-based food pantries may be one mechanism for reducing ED use among low-income patients with diabetes.

Addressing food insecurity in HIV care: perspectives from healthcare and social service providers in New York state

Ending the HIV epidemic in the United States will require addressing social determinants contributing to poor care engagement among people living with HIV (PLH), such as food insecurity. Food insecurity is associated with poor care engagement among PLH. Yet, few studies have examined the perspectives of healthcare and social services providers on addressing food insecurity in HIV care. Guided by the Social Ecological Model, we conducted semi-structured interviews with 18 providers in New York State to understand barriers and facilitators to addressing food insecurity in HIV care. Thematic analysis illustrated eight themes across various levels of the Social Ecological Model. At the patient-level, providers perceived patients' feelings of embarrassment, shame, and judgement, and low health literacy as barriers. At the provider-level, challenges included limited time. Facilitators included fostering strong, patient-provider relationships. Barriers at the clinic-level included limited funding, while clinic resources served as facilitators. At the community-level, challenges included intersecting stigmas arising from community norms towards PLH and people who receive food assistance and limited access to healthy food. Findings suggest the need to incorporate their insights into the development of interventions that address food insecurity in HIV care.

Differential utilization of the online patient portal for completion of health-related social needs screening during routine gynecologic cancer care

BACKGROUND

Telehealth technologies offer efficient ways to deliver health-related social needs (HRSN) screening in cancer care, but these methods may not reach all populations. The authors examined patient characteristics associated with using an online patient portal (OPP) to complete HRSN screening as part of gynecologic cancer care.

METHODS

From June 2021 to June 2023, patients in a gynecologic oncology clinic completed validated HRSN screening questions either (1) using the OPP (independently before the visit) or (2) in person (verbally administered by clinic staff). The authors examined the prevalence of HRSN according to activated OPP status and, in a restricted subgroup, used stepwise multivariate Poisson regression to identify associations between patient and visit characteristics and using the OPP.

RESULTS

Of 1616 patients, 87.4% (n = 1413) had an activated OPP. Patients with inactive OPPs (vs. activated OPPs) more frequently reported two or more needs (10% vs 5%; p < .01). Of 986 patients in the restricted cohort, 52% used the OPP to complete screening. The final multivariable model indicated that patients were less likely to use the OPP if they were Black (vs. White; adjusted relative risk [aRR], 0.70; 95% confidence interval [CI], 0.59-0.83); not employed (vs. employed; aRR, 0.81; 95% CI, 0.68-0.97), or had low measures of OPP engagement (aRR, 0.80; 95% CI, 0.68-0.92). New versus established patients were 21% more likely to use the OPP (aRR, 1.21; 95% CI, 1.06-1.38).

CONCLUSIONS

Differential use of the OPP suggested that over-reliance on digital technologies could limit the ability to reach those populations that have social factors already associated with cancer outcome disparities. Cancer centers should consider using multiple delivery methods for HRSN screening to maximize reach to all populations.

Using Photovoice to Improve Engagement in Community Health Assessments Addressing Behavioral Health

Behavioral health disorders are well-known to have close links with the social determinants of health, yet little is known about how impacted communities perceive these links. Qualitative participatory methods can not only provide insight into how communities conceptualize these relationships but also empower those with lived experience to contextualize their perspectives and formulate calls to action. This study used Photovoice as a participatory method to supplement the Clark County Health Department Community Health Assessment and determine priority facilitators and barriers contributing to the behavioral health of Clark County, KY, residents. A secondary aim was to gain a greater understanding of how the Photovoice methodology impacts community engagement efforts in Community Health Assessments. Twenty-three Clark County residents participated in four Photovoice groups involving five weekly sessions, which included photograph "show and tell," critical group dialogue, participatory analysis, and planning for dissemination. Secondary analysis of Photovoice focus group discussions revealed behavioral health facilitators and barriers were most influenced by (1) public sector unresponsiveness, (2) strong partnerships formed between community and grassroots organizations, and (3) the siloed division of responsibility between agencies and across sectors. The authors also found the Photovoice method successfully enhanced engagement and empowered those with lived experience to frame their perspectives of the behavioral health landscape. This project has implications for enhancing community engagement and empowerment in behavioral health-focused public health assessments and shaping policy to promote multi-sector collaboration.

Integration of social determinants of health information within the primary care electronic health record: a systematic review of patient perspectives and experiences

BACKGROUND

Social determinants of health (SDOH) are the non-medical factors that impact health. Although geographical measures of deprivation are used, individual measures of social risk could identify those most at risk and generate more personalised care and targeted referrals to community resources. We know SDOH are important to health care, but it is not yet known whether their collection via the electronic health record (EHR) is acceptable and useful from the patient perspective.

AIM

To synthesise relevant literature to explore patient perspectives on integrating information about SDOH into primary care EHRs, and the opportunities and challenges of its implementation in a general practice setting.

DESIGN & SETTING

Systematic review of primary care-based qualitative and mixed-method studies using thematic framework analysis.

METHOD

Key databases were searched for articles reporting patient perspectives of SDOH collection within the primary care EHR. Qualitative and mixed-methods studies written in English were included. A framework analysis was conducted to identify themes.

RESULTS

From 14 included studies, the following five main themes were identified: rationale for SDOH screening and the anticipated outcomes; impact of the provider-patient relationship on patient perceptions; data, which included privacy concerns; screening process and referral; and recommendations for future research.

CONCLUSION

Integration of information on SDOH into the EHR appears acceptable to patients. This review has added to the discussion of whether and how to implement SDOH screening and referral programmes into UK primary care systems.

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.

Social Determinants of Health and Allergic Disease Prevalence Among Asian American Children

BACKGROUND

Although racial and ethnic disparities in allergic diseases have previously been observed, the relationship between social determinants of health (SDoH) and allergic disease prevalence among disaggregated Asian American (AsA) subgroups is poorly understood.

OBJECTIVE

To examine the association of SDoH with allergic disease prevalence among disaggregated AsA subgroups.

METHODS

Using the 2011-2018 National Health Interview Survey, we examined caregiver-reported race and ethnicity, SDoH, and allergic diseases. We compared survey-weighted allergic disease prevalence by AsA subgroup. Subgroup-stratified multivariable logistic regression accounting for age, sex, child/parent nativity, and survey year modeled the association between SDoH and allergic disease prevalence. We provide predicted probabilities of having each allergic disease based on exposure to each SDoH.

RESULTS

We examined data from 5042 non-Hispanic AsA children representing 3,264,768 AsA children. Approximately 25% of all AsA children reported at least one allergic disease, ranging from 20% of Asian Indian children to 30% of Filipino/a children. The number of unfavorable SDoH was lowest among Asian Indian and Chinese children (mean 0.7) and highest among "other Asian" children (mean 1.2). In stratified analyses, financial instability and inaccessible healthcare were associated with greater probability of allergic diseases among some, but not all AsA subgroups. Lower parent education level, food insecurity, and rent/other housing arrangement were associated with lower probability of allergic disease among some AsA children.

CONCLUSION

There was heterogeneity in the association of SDoH and allergic disease prevalence among AsA children. Further study of SDoH may inform modifiable environmental factors for allergic disease among AsA children.

Surgeon Understanding and Perceptions of Social Determinants of Health

INTRODUCTION

Social determinants of health impact surgical outcomes. Characterization of surgeon understanding of social determinants of health is necessary prior to implementation of interventions to address patient needs. The study objective was to explore understanding, perceived importance, and practices regarding social determinants of health among surgeons.

METHODS

Surgical residents and attending surgeons at a single academic medical center completed surveys regarding social determinants of health. We conducted semi-structured interviews to further explore understanding and perceived importance. A conceptual framework from the World Health Organization (WHO) Commission on Social Determinants of Health informed the thematic analysis.

RESULTS

Survey response rate was 47.9% (n = 69, 44 residents [63.8%], 25 attendings [36.2%]). Respondents primarily reported good (n = 29, 42.0%) understanding of social determinants of health and perceived this understanding to be very important (n = 42, 60.9%). Documentation occurred seldom (n = 35, 50.7%), and referrals occurred seldom (n = 26, 37.7%) or never (n = 20, 29.0%). Residents reported a higher rate of prior training than attendings (95.5% versus 56.0%, P < 0.001). Ten interviews were conducted (six residents, four attendings). Residents demonstrated greater understanding of socioeconomic positions and hierarchies shaped by structural mechanisms than attendings. Both residents and attendings demonstrated understanding of intermediary determinants of health status and linked social determinants to impacting patients' health and well-being. Specific knowledge gaps were identified regarding underlying structural mechanisms including the social, economic, and political context that influence an individual's socioeconomic position.

CONCLUSIONS

Self-reported understanding and importance of social determinants of health among surgeons were high. Interviews revealed gaps in understanding that may contribute to limited practices.

Social workers are key to addressing social determinants of health in integrated care settings

Social workers play an important role in assessing social determinants of health (SDH) and providing behavioral health services in integrated care settings. Evidence suggests that integrated care interventions improve quality of life and other patient outcomes. However, the ambiguous role of social workers on the interdisciplinary team, the lack of protocol in SDH screening and intervention, and restrictions due to healthcare reimbursement limit social workers' ability to intervene. Future directions include standardizing integrated care models, evaluating integrated care's efficacy to address SDH, incorporating SDH into interprofessional training including role clarification and reimbursing for SDH assessment and intervention.

Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans

BACKGROUND

Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services.

OBJECTIVE

To study associations between social risks and primary care utilization among patients with medical complexity.

DESIGN

Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion.

PARTICIPANTS

Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death.

MAIN MEASURES

Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter.

KEY RESULTS

Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of  ≥ 1 social work encounter.

CONCLUSIONS

We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.

Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system

Introduction

Health systems have many incentives to screen patients for health-related social needs (HRSNs) due to growing evidence that social determinants of health impact outcomes and a new regulatory context that requires health equity measures. This study describes the experience of one large urban health system in scaling HRSN screening by implementing improvement strategies over five years, from 2018 to 2023.

Methods

In 2018, the health system adapted a 10-item HRSN screening tool from a widely used, validated instrument. Implementation strategies aimed to foster screening were retrospectively reviewed and categorized according to the Expert Recommendations for Implementing Change (ERIC) study. Statistical process control methods were utilized to determine whether implementation strategies contributed to improvements in HRSN screening activities.

Results

There were 280,757 HRSN screens administered across 311 clinical teams in the health system between April 2018 and March 2023. Implementation strategies linked to increased screening included integrating screening within an online patient portal (ERIC strategy: involve patients/consumers and family members), expansion to discrete clinical teams (ERIC strategy: change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical data to providers), and deploying Community Health Workers to address HRSNs (ERIC strategy: create new clinical teams).

Conclusion

Implementation strategies designed to promote efficiency, foster universal screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening demonstrate the cumulative effects of implementation strategies and the health system's commitment toward universal screening.

Assessment and Documentation of Social Determinants of Health Among Health Care Providers: Qualitative Study

BACKGROUND

Research clearly demonstrates social determinants of health (SDOH) impact health outcomes. Provider consideration of patient SDOH in prevention and treatment planning is critical for improved health care quality and health equity. Despite awareness of the connections between SDOH and improved population health, research demonstrates few providers document patient SDOH.

OBJECTIVE

This qualitative study aimed to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles.

METHODS

Individual semistructured interviews were conducted with practicing health care providers in South Carolina between August 25, 2022, and September 2, 2022. Participants were recruited via community partners' web-based newsletters or listservs using a purposive sampling design. An interview guide with 19 questions was used to explore the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH?

RESULTS

Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor (licensed clinical social worker) with careers spanning 12 to 32 years. Participant responses are presented according to the following 5 themes: participants' understanding of SDOH for the patient population, assessment and documentation practices, referrals to other providers and community-based resources, barriers and facilitators of SDOH assessment and documentation, and SDOH assessment and documentation training preferences. Overall, participants were aware of the importance of including patient SDOH in assessment and intervention but noted a variety of institutional and interpersonal barriers to assessment and documentation, including time constraints, perceptions of stigma around discussion of SDOH, and limited referral protocols.

CONCLUSIONS

Incentivizing inclusion of patient SDOH in health care must be facilitated from the top down, so assessment and documentation can be universally implemented in a pragmatic way that works for providers in a variety of roles and settings for the betterment of health care quality, health equity, and improved population health outcomes. Partnering with community organizations can serve to augment health care organizations' resource and referral availability for addressing patients' social needs.

Does Self-Perceived Diet Quality Align with Nutrient Intake? A Cross-Sectional Study Using the Food Nutrient Index and Diet Quality Score

A reliable diet quality (DQ) assessment is critical to empower individuals to improve their dietary choices. Controversies persist as to whether self-perceived DQ is accurate and correlated with actual DQ as assessed by validated nutrient intake indexes. We used National Health and Nutrition Examination Surveys data to examine whether a higher self-perceived DQ was positively associated with a more optimal nutrient intake as reflected by the Food Nutrient Index (FNI) and Diet Quality Score (DQS). Comparative analyses were performed for three self-perceived DQ groups: (I) "excellent or very good" DQ, (II) "good or fair" DQ, and (III) "poor" DQ. The FNI and DQS differed substantially across groups and sexes. FNI scores ranged from 65 to 69 in participants with a self-reported excellent or very good DQ, whereas participants with a self-perceived poor DQ scored significantly lower (53-59). We also observed age- and sex-specific patterns, with the lowest overall FNI scores found in males aged 18-30 years and females aged 31-50 years. DQ intergroup differences were more pronounced in females than in males. Our findings suggest that higher self-perceived DQ is associated with a more optimal nutrient intake and indicate potential helpfulness of self-perceived DQ as a quick and still underexplored indicator with intrinsic limitations.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization

Importance

Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources.

Objective

To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program.

Design, Setting, and Participants

This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees.

Main Outcomes and Measures

Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness).

Results

Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food.

Conclusions and Relevance

This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.

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.

Assessing Differences in Social Determinants of Health Screening Rates in a Large, Urban Safety-Net Health System

INTRODUCTION/OBJECTIVE

Previous studies have evaluated the implementation of standardized social determinants of health (SDOH) screening within healthcare settings, however, less is known about where screening gaps may exist following initial implementation based on facility characteristics. The objective of this study is to assess differences in screening rates for SDOH at a large, urban healthcare system.

METHODS

We used electronic health record data obtained from NYC Health + Hospitals primary care sites from 2019 to 2022. We calculated the mean number of visits that were SDOH screened by visit type, facility size, and the percentages of community characteristics. We conducted 4 logistic regression models predicting the odds of screening for any SDOH and for specific SDOH needs (housing, food, and medical cost assistance) based on facility type, facility size, and the socioeconomic characteristics of the surrounding community.

RESULTS

Among the 3 212 650 visits included, 16.90% were SDOH screened. Across all 4 multivariate logistic regression models predicting SDOH screening, a visit had significantly lower odds of being screened if based at a midsize or small facility, if it was a telemedicine visit, or based at a facility located in a zip-code with a higher percentage of SDOH needs.

CONCLUSIONS

Our study found important differences in SDOH screening rates at a large, NYC-based health system based on size, visit type, and community level characteristics. In particular, our findings point to barriers related to facility size and telemedicine workflow that should be addressed to increase uptake of SDOH screening within different visits and facility types.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity.

DATA SOURCES

Administrative data from the Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects.

DATA COLLECTION

We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity.

PRINCIPAL FINDINGS

Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population.

CONCLUSIONS

Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Caregiver Experiences in Pediatric Hospitalizations: Challenges and Opportunities for Improvement

BACKGROUND

There are limited qualitative data describing general pediatric hospitalizations through the caregivers' lens, and most focus on one particular challenge or time during the hospitalization. This qualitative study aimed to address a gap in the description of the breadth and depth of personal challenges caregivers may face during the entire hospitalization, irrespective of severity of patient illness or diagnosis, and explored caregiver-suggested interventions.

METHODS

Caregivers of pediatric patients on the hospitalist service at a Pacific Northwest children's hospital were interviewed to explore their hospitalization experience and solicit feedback for potential interventions. Content was coded iteratively using a framework analysis until thematic saturation was met. Findings were triangulated through 2 focus groups, 1 with parent advisors and the other with hospital physicians and nurses.

RESULTS

Among 14 caregivers (7 each of readmitted and newly admitted patients) and focus group participants, emergent domains on difficulties faced with their child's hospitalization were anchored on physiologic (sleep, personal hygiene, and food), psychosocial (feelings of isolation, mental stress), and communication challenges (information flow between families and the medical teams). Caregivers recognized that addressing physiologic and psychosocial needs better enabled them to advocate for their child and suggested interventions to ameliorate hospital challenges.

CONCLUSIONS

Addressing physiologic and psychosocial needs may reduce barriers to caregivers optimally caring and advocating for their child. Downstream consequences of unaddressed caregiver challenges should be explored in relation to participation in hospital care and confidence in shared decision-making, both vital components for optimization of family-centered care.

"It Made Me Feel like Things Are Starting to Change in Society:" A Qualitative Study to Foster Positive Patient Experiences during Phone-Based Social Needs Interventions

Many healthcare organizations are screening patients for health-related social needs (HRSN) to improve healthcare quality and outcomes. Due to both the COVID-19 pandemic and limited time during clinical visits, much of this screening is now happening by phone. To promote healing and avoid harm, it is vital to understand patient experiences and recommendations regarding these activities. We conducted a pragmatic qualitative study with patients who had participated in a HRSN intervention. We applied maximum variation sampling, completed recruitment and interviews by phone, and carried out an inductive reflexive thematic analysis. From August to November 2021 we interviewed 34 patients, developed 6 themes, and used these themes to create a framework for generating positive patient experiences during phone-based HRSN interventions. First, we found patients were likely to have initial skepticism or reservations about the intervention. Second, we identified 4 positive intervention components regarding patient experience: transparency and respect for patient autonomy; kind demeanor; genuine intention to help; and attentiveness and responsiveness to patients' situations. Finally, we found patients could be left with feelings of appreciation or hope, regardless of whether they connected with HRSN resources. Healthcare organizations can incorporate our framework into trainings for team members carrying out phone-based HRSN interventions.

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

Background

Social care has become increasingly relevant to the emergency physician and includes activities that address health-related social risk and social needs. The literature has consistently documented substantial health care provider challenges in incorporating social care into routine practice. Yet, interventions on the health care organizational level hold promise to bring about more widespread, sustainable impact.

Methods

This study was a subanalysis of the 2021 National Social Care Practices Survey data set among pediatric emergency medicine (PEM) program directors (PDs) and fellows. The purpose was to investigate the association between health care organizational factors and PEM physician social care practices and perceptions among PEM PDs and fellows. We performed binary and ordinal logistic regressions of organizational factors and five specific PEM physician social care perspective and practice outcomes.

Results

The sample population included 153 physicians-44 PDs (49% response rate) and 109 fellows (28%). PDs and fellows with access to a social care systematic workflow in their pediatric emergency department (PED) had higher odds of comfort assessing social risk (odds ratio [OR] 2.1%, 95% confidence interval [CI] 1.1-4.0), valuation of social care (OR 3.2, 95% CI 1.3-7.9), preparedness to assist families (OR 2.4, 95% CI 1.1-5.2), screening tendency (OR 2.2, 95% CI 1.1-4.5), and ability to refer to community resources (OR 2.3, 95% CI 1.2-4.6). A similarly directed, but less pronounced pattern was noted with access to a community resource database for referrals and 24-h access to a social worker in the PED.

Conclusions

PED organizational factors-particularly access to a social care systematic workflow-appear positively associated with PEM physician practices and perceptions of social care delivery. Further research is under way to advance understanding of PEM training factors in social care.

Examining Social Determinants of Health During a Pandemic: Clinical Application of Z Codes Before and During COVID-19

Recognition of the impact of social determinants of health (SDoH) on healthcare outcomes, healthcare service utilization, and population health has prompted a global shift in focus to patient social needs and lived experiences in assessment and treatment. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provides a list of non-billable “Z codes” specific to SDoH for use in electronic health records. Using population-level analysis, this study aims to examine clinical application of Z codes in South Carolina before and during the COVID-19 pandemic. The study population consists of South Carolina residents who had a healthcare visit and had their COVID-19 test result reported to the state's Department of Health and Environmental Control before January 14, 2021. Of the 1,190,531 individuals in the overall sample, Z codes were used only for 14,665 (1.23%) of the patients, including 2,536 (0.97%) COVID-positive patients and 12,129 (1.30%) COVID-negative patients. Compared with hospitals that did not use Z codes, those that did were significantly more likely to have higher bed capacity (p = 0.017) and to be teaching hospitals (p = 0.03), although this was significant only among COVID-19 positive individuals. Those at inpatient visits were most likely to receive Z codes (OR: 5.26; 95% CI: 5.14, 5.38; p < 0.0001) compared to those at outpatient visits (OR: 0.07; 95%CI: 0.06, 0.07; p < 0.0001). There was a slight increase of Z code use from 2019 to 2020 (OR: 1.33, 95% CI: 1.30, 1.36; p < 0.0001), which was still significant when stratified by facility type across time. As one of the first studies to examine Z code use among a large patient population, findings clearly indicate underutilization by providers. Additional study is needed to understand the potentially long-lasting health effects related to SDoH among underserved populations.

Social care practices and perspectives among U.S. pediatric emergency medicine fellowship programs

BACKGROUND

The emergence of social emergency medicine-the incorporation of social context into the structure and practice of emergency care-has brought forth greater embracement of the social determinants of health by medical professionals, yet workforce practices and training have remained elusive. Academic literature particularly in the field of pediatric emergency medicine (PEM) fellowship training is lacking relative to general pediatrics and adult emergency medicine.

METHODS

The primary objective of this study was to assess the social care knowledge, perspectives, and training of PEM program directors (PDs) and fellows across a national cross-sectional sample. A secondary aim was to uncover key actionable areas for the development of social care curricula in PEM training programs. A social care practices assessment tool was developed via snowball sampling interviews among clinician researcher experts and disseminated to PEM PDs and fellows nationally in accredited academic PEM training institutions.

RESULTS

A total of 153 participants-44 PDs (49% response rate) and 109 fellows (28%)-completed the assessment tool. Responses among PDs and fellows were highly concordant. Only 12% reported regular use of a standardized social needs screening tool. The majority felt unprepared to assist families with social needs and less than half felt comfortable talking to families about social need. At the same time, social care was highly valued by 73% of participants. All participants felt that providing social care training during PEM fellowship would be beneficial. PDs and fellows identified five priority areas for PEM curricular development.

CONCLUSIONS

PEM PDs and fellows have an overall favorable perception of social care yet report significant deficits in current practice organization and training. This study is part of a larger national collaborative advocacy project to organize and advance social care delivery across academic PEM training institutions through evidence-based approaches, best practices, and expert consensus.

Implementing Health Related Social Needs Screening in an Outpatient Clinic

INTRODUCTION/OBJECTIVES

Health-related social needs (HRSN) screening efforts have reported high rates of identified social needs. Little is known if efforts to conduct HRSN screening in resource-constrained federally-qualified health centers (FQHC) successfully captures a representative patient population.

METHODS

This cross-sectional study extracted EMR data from 2016 to 2020 for 4731 screened patients from 7 affiliated clinics of a FQHC. Unscreened patients were pulled as a random sample from the study period. A multivariable logistic regression was used to identify sociodemographic traits, chronic disease diagnoses and burden, and clinic visit type and frequency associated with being screened for HRSN.

RESULTS

BHC screened 4731 unique patients or <1% of the total clinic population. Screened patients had a median of 3.3 (±2.5) unmet HRSN. Medicaid patients had higher odds of being screened (aOR = 1.38, CI 1.19-1.61) relative to Medicare patients. The odds of being screened for social needs increased with more provider visits per year: compared to fewer than 1 visit per year, patients with 1 to 3 provider visits (aOR = 2.06, CI 1.73-2.32), 4 to 6 provider visits (aOR = 3.34, CI 2.89-3.87), and more than 6 provider visits (aOR = 5.16, CI 4.35-6.12) all had higher odds of social needs screening. Patients with a higher comorbid disease burden (>2 conditions, aOR = 2.80, CI 2.07-3.79) had higher odds of screening.

CONCLUSIONS

Our findings demonstrate an increased likelihood to screen patients who visit outpatient services more often and have a higher comorbid disease burden. To meet state-level Medicaid requirements, resource-constrained FQHCs that implement clinic wide HRSN screening may be well served to identify a priori strategies to ensure representative and equitable screening across the patient population.