Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework

A family-centered approach to social needs awareness in the pediatric emergency department

Objective

We aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits.

Methods

Families were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference.

Results

Forty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone (p < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion.

Conclusions

Assessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts.

Innovation

Use of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets.

Barriers to identifying and addressing health-related social needs in cancer care: Patient and patient navigator perspectives

BACKGROUND

The study aimed to gain insight into the experiences of patients with cancer and survivors regarding the integration of social needs assessment into their care, while also gathering perspectives from patient navigators on the barriers to obtaining and utilizing social needs information during cancer care, which taken together may influence cancer care policies. By comparing the perspectives of patients and navigators, the study sought to inform best practices for integrating, identifying, and addressing social needs to improve patient experiences and outcomes.

METHODS

We conducted qualitative interviews and self-report surveys involving patients with cancer, providers, and patient navigators or care coordinators, seeking their insights and firsthand experiences related to health-related social needs in cancer care. Interviews were transcribed, separated into memos of main themes based on deductive coding, and further analyzed for new emergent themes using inductive coding.

RESULTS

The present analysis focuses solely on the perspectives of 20 patient navigators and 21 patients. Qualitative analyses revealed two overarching themes: Theme 1: Personal and health system-related factors may create barriers for patients to disclose health-related social needs information during cancer care; and Theme 2: When social needs are identified, it is best practice to acknowledge and address social needs through referrals, resources, timely follow-up, and continued care coordination. Key barriers include individual beliefs and attitudes, concerns regarding privacy and sensitivity of questions, uncertainties about the outcomes of disclosing information, and patient-provider relationships and trust.

CONCLUSION

Drawing upon the perspectives of patients and patient navigators provided valuable insight into the challenges associated with acquiring information on social needs. Their viewpoints presented feasible solutions to overcome barriers through early acknowledgment of patient needs, timely resource provision, and maintaining consistent follow-up actions. Additionally, it enhanced understanding of the pivotal role patient navigators play in oncology, serving as crucial links between screening for health-related social needs and addressing individual patient requirements.

POLICY SUMMARY

The policies and policy improvements our paper seeks to impact include: inequalities in cancer care and health-related social needs of cancer.

Applying health equity implementation science frameworks to population genetic screening

Introduction

Implementation science frameworks with a focus on health equity have emerged to help guide the introduction of new interventions into healthcare and community settings while limiting health disparities. The purpose of this research was to explore the applicability of such frameworks to guide the equitable implementation of population genetic screening programs.

Methods

We searched PubMed and reference lists for relevant frameworks and examples of their use in health settings. We then assessed if and how selected frameworks provide guidance for different stages of population genetic screening: recruitment, sample collection, result return, follow-up care and long-term management, and cascade screening. Findings were synthesized into a list of health equity considerations specific to each stage.

Results

We identified 5 implementation frameworks that focus on health equity. Guidance varied by framework type: determinant (explaining what affects implementation outcomes), process (translating research into practice), or evaluation (assessing implementation). Common characteristics included focusing implementation efforts on populations who have historically experienced health inequities and adapting interventions to fit local contexts. Process models also highlighted the importance of community partnerships.

Discussion

Overall, frameworks offered broad recommendations applicable to population genetic screening program implementation. However, gaps still exist in guidance provided for later stages of population genetic screening. To improve the equitable implementation of genetic screening, future programs may benefit from utilizing one or more of these frameworks or by incorporating the health equity considerations and outcomes compiled in this analysis.

Factors affecting U.S. adults' comfort level in sharing social needs information with healthcare providers

OBJECTIVE

This study examines various factors affecting U.S. adults' comfort level in sharing information about their social needs with healthcare providers.

METHODS

We used data from the 2022 Health Information National Trends Survey (cycle 6), a nationally representative survey of U.S. adults (n = 6252). The outcome variables were participants' comfort level in sharing information about three social needs (food insecurity, transportation difficulties, and housing instability). Data were analyzed using weighted bivariate and multivariable logistic regression models.

RESULTS

Participants who faced discrimination when getting medical care based on race/ethnicity were more likely to be uncomfortable in sharing information about food insecurity, housing instability, and transportation difficulties. Those who trusted the healthcare system "a lot" were less likely to be uncomfortable in sharing information about food insecurity and transportation difficulties. Patient-Centered Communication (PCC) and social isolation scores significantly affected participants' comfort level in sharing information about social needs.

CONCLUSION

Various factors such as trust, discrimination, social isolation, and PCC were found to be significantly affecting US adults' comfort level in sharing information about social needs.

PRACTICE IMPLICATIONS

Healthcare systems and policymakers should focus on developing approaches and strategies to enhance trust, reduce discrimination, improve patient-provider communication, and create supportive social environments.

Neighborhood Disadvantage Predicts Delay in Care in Bilateral Breast Reduction

PURPOSE

The Area Deprivation Index (ADI) is a validated quantifiable measure of neighborhood disadvantage and social determinants of health (SDoH). Higher percentiles in ADI correlate with the most disadvantaged neighborhoods: lower income, lower education, and less access to transportation. Using ADI, we aimed to investigate the impact of SDoH on bilateral breast reduction (BBR) complication rates.

METHODS

A retrospective study of BBR patients from 2015 to 2021 was conducted. Patient addresses were matched to ADI percentiles and grouped into most (top 80% ADI) and least disadvantaged. Multivariable regressions were used to compare postoperative treatment between groups and adjust for confounders.

RESULTS

In total, 568 patients were analyzed and 47% were high ADI. Time-to-event analysis revealed a 155% (β = 2.55; CI, 1.87-3.48; P < 0.001) increase in time to presentation for treatment of wound-related complications among higher-deprivation patients compared to their lower-deprivation counterparts. This difference in time to presentation equated to approximately 3 days overall when comparing higher to lower deprivation patients; however, this difference between the groups increased to 12 days when comparing those who experienced wound-related complications beyond day 30.

CONCLUSIONS

High deprivation was associated with increased delays to treatment after complications. More research is needed to determine the factors that impact postoperative courses among high ADI patients.

How to leverage implementation research for equity in global health

Implementation research (IR) is important for addressing equity in global health. However, there is limited knowledge on how to operationalize IR for health equity, and pathways for improving health equity through IR in global health settings. This paper provides an overview of guidance and frameworks for thinking about health equity as part of IR while noting the gaps in how this guidance and frameworks apply to global health. It proposes an approach to guide implementation teams in the application of IR for achieving equity in global health considering these gaps. It describes key equity considerations for different aspects of IR (i.e., implementation contexts, strategies, outcomes, and research designs). These considerations can be applied prospectively and retrospectively, and at different stages of IR. The paper further describes causal pathways, intervention levers, and strategies for achieving health equity in global health settings through IR. Central to these pathways is the power asymmetries among different actors involved in IR in global health and how these contribute to health inequities. The paper suggests recommendations and strategies for shifting the balance of power among these actors while addressing the structural and systemic determinants of health inequities as part of IR. Explicit considerations for health equity as part of implementation research and practice are needed for the achievement of global health goals. Such explicit considerations should look back as much as possible, and entail defining and analyzing health inequities and intervening on the underlying causes and mechanisms of health inequities as part of IR on a routine basis.

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.

COVID-19 Disruptions to Social Care Delivery: A Qualitative Study in Two Large, Safety-Net Primary Care Clinics

BACKGROUND

Social care integration refers to the incorporation of activities into health systems that assist patients with health-related social needs (HRSNs) that negatively impact the health outcomes of their patients, such as food insecurity or homelessness. Social care integration initiatives are becoming more common. The COVID-19 pandemic strained health systems while simultaneously increasing levels of unmet social needs.

OBJECTIVE

To describe the effects of the COVID-19 pandemic on established social care delivery in a primary care setting.

DESIGN

We used qualitative semi-structured interviews of stakeholders to assess barriers and facilitators to social care delivery in the primary care setting during the COVID-19 health emergency. Data was analyzed using a hybrid inductive/deductive thematic analysis approach with both the Consolidated Framework for Implementation Research (CFIR) and the Screen-Navigate-Connect-Address-Evaluate model of social care integration.

SETTING

Two safety-net, hospital-based primary care clinics with established screening for food insecurity, homelessness, and legal needs.

PARTICIPANTS

Six physicians, six nurses, six members of the social work team (clinical social workers and medical case workers), six community health workers, and six patients (total N = 30) completed interviews.

RESULTS

Four major themes were identified. (1) A strained workforce experienced challenges confronting increased levels of HRSNs. (2) Vulnerable populations experienced a disproportionate negative impact in coping with effects of the COVID-19 pandemic on HRSNs. (3) COVID-19 protections compounded social isolation but did not extinguish the sense of community. (4) Fluctuations in the social service landscape led to variable experiences.

CONCLUSIONS

The COVID-19 pandemic disrupted established social care delivery in a primary care setting. Many of the lessons learned about challenges to social care delivery when health systems are strained are important considerations that can inform efforts to expand social care delivery.

Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting

BACKGROUND

Community health workers (CHWs) remain an underutilized resource in social risk diagnostics in the primary care setting. This process evaluation study seeks to assess the role of CHWs in social risk screening, referral, and follow-up through process mapping to identify barriers to the process for future quality improvement efforts.

METHODS

Researchers at the Arizona Prevention Research Center (AzPRC) engaged with two Federally Qualified Health Centers (FQHCs) in two of Arizona's major urban areas to evaluate their internal processes for social risk screening and intervention. The Consolidated Framework for Implementation Research (CFIR) was used to direct a process mapping exercise to visually describe the workflow, gaps, and barriers to identifying and addressing social risk.

RESULTS

The process unveiled key areas for health system improvements in the community setting, the organizational setting, and in the implementation of social risk screening, referral, and follow-up. Further, process maps highlight the potential resources needed for effective CHW integration to address social risk in the primary care setting.

CONCLUSIONS

Our findings demonstrate the importance of organizational tools, such as process mapping, to assist primary care settings in evaluating internal processes for quality improvement in addressing social risk and in effectively integrating the CHW workforce. Subsequent research will evaluate rates of social risk screening, referral, and follow-up within all of Arizona's FQHCs and propose models for CHW integration to address social risk in primary care and strengthen social risk screening reach and effectiveness.

Association of Patient-Reported Social Needs with Emergency Department Visits and Hospitalizations Among Federally Qualified Health Center Patients

BACKGROUND

Health care systems are increasingly screening for unmet social needs. The association between patient-reported social needs and health care utilization is not well understood.

OBJECTIVE

To investigate the association between patient-reported social needs, measured by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), and inpatient and emergency department (ED) utilization.

DESIGN

This cohort study analyzed merged 2017-2019 electronic health record (EHR) data across multiple health systems.

PARTICIPANTS

Adult patients from a federally qualified health center (FQHC) in central North Carolina who completed PRAPARE as part of a primary care visit with behavioral health services.

MAIN MEASURES

The count of up to 12 unmet social needs, aggregated as 0, 1, 2, or 3 + . Outcomes include the probability of an ED visit and hospitalization 12 months after PRAPARE assessment, modeled by logistic regressions controlling for age, sex, race, ethnicity, comorbidity burden, being uninsured, and prior utilization in the past 12 months.

KEY RESULTS

The study population consisted of 1924 adults (38.7% male, 50.1% Black, 36.3% Hispanic, 55.9% unemployed, 68.2% of patients reported 1 + needs). Those with more needs were younger, more likely to be unemployed, and experienced greater comorbidity burden. 35.3% of patients had ED visit(s) and 36.3% had hospitalization(s) 1 year after PRAPARE assessment. In adjusted analysis, having 3 + needs was associated with a percentage point increase in the predicted probability of hospitalization (average marginal effect 0.06, SE 0.03, p < 0.05) compared with having 0 needs. Similarly, having 2 needs (0.07, SE 0.03, p < 0.05) or 3 + needs (0.06, SE 0.03, p < 0.05) was associated with increased probability of ED visits compared to 0 needs.

CONCLUSIONS

Patient-reported social needs were common and associated with health care utilization patterns. Future research should identify interventions to address unmet social needs to improve health and avoid potentially preventable escalating medical intervention.

Barriers and facilitators to screen for and address social needs in primary care practices in Maryland: a qualitative study

Background

Social needs screening can help modify care delivery to meet patient needs and address non-medical barriers to optimal health. However, there is a need to understand how factors that exist at multiple levels of the healthcare ecosystem influence the collection of these data in primary care settings.

Methods

We conducted 20 semi-structured interviews involving healthcare providers and primary care clinic staff who represented 16 primary care practices. Interviews focused on barriers and facilitators to awareness of and assistance for patients' social needs in primary care settings in Maryland. The interviews were coded to abstract themes highlighting barriers and facilitators to conducting social needs screening. The themes were organized through an inductive approach using the socio-ecological model delineating individual-, clinic-, and system-level barriers and facilitators to identifying and addressing patients' social needs.

Results

We identified several individual barriers to awareness, including patient stigma about verbalizing social needs, provider frustration at eliciting needs they were unable to address, and provider unfamiliarity with community-based resources to address social needs. Clinic-level barriers to awareness included limited appointment times and connecting patients to appropriate community-based organizations. System-level barriers to awareness included navigating documentation challenges on the electronic health record.

Conclusions

Overcoming barriers to effective screening for social needs in primary care requires not only practice- and provider-level process change but also an alignment of community resources and advocacy of policies to redistribute community assets to address social needs.

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.

Improving Hypertension Control in the Black Patient Population: A Quality Improvement Study of Workflow Redesign Using the Electronic Health Record to Integrate Self-Monitoring, Education, and Reporting

BACKGROUND

Nearly half of American adults have hypertension (HTN), and non-Hispanic Black patients are diagnosed at a higher rate than others.

LOCAL PROBLEM

Our local clinic population reflected disproportionate rates of uncontrolled HTN among Black patients.

METHODS

A quality improvement pre-/postintervention design was used to evaluate an educational intervention to reduce blood pressure (BP) and improve self-monitoring of BP in Black patients using the Chronic Care Model.

INTERVENTIONS

A team-based approach was used to redesign clinic workflows and patient education, prescribe self-paced videos from an electronic health record (EHR) patient portal, and provide home BP cuffs.

RESULTS

Black participants (n = 79) improved viewing of prescribed videos (7.9% to 68.5%), knowledge scores (67.9 to 75.2), and mean systolic BP (-20.3 mm Hg; P > .001).

CONCLUSIONS

This team-based approach enhanced patient engagement, self-monitoring skills, EHR-reported BP, and overall BP control for a cohort of Black patients with uncontrolled BP.

Use of and barriers to adopting standardized social risk screening tools in federally qualified health centers during the first year of the COVID-19 pandemic

OBJECTIVE

To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020.

DATA SOURCE

2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375).

STUDY DESIGN

We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers.

DATA COLLECTION

None.

PRINCIPAL FINDINGS

In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%).

CONCLUSIONS

Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.

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.

Social Needs Screening and Intervention in Pediatric Primary Care: Impact on Families' Experience of Care

INTRODUCTION/OBJECTIVES

Social determinants of health (SDoH) screening and intervention in pediatric primary care depends upon caregiver disclosure of adverse household or social conditions and thus may be influenced by perceived bias or stigma. This paper examines to what extent parents' experience of their child's medical home is associated with their perceptions of a practice-based social needs intervention.

METHODS

We conducted a cohort study of data reported by 73 parents of children obtaining care in a medical home with an embedded SDoH navigation program. Using survey data collected in October 2021 and October 2022, we calculated descriptive statistics and non-parametric bivariate analyses of the association between engagement with the SDoH navigation program and parent-reported social needs, stress, and perception of care quality as measured by the Person-Centered Primary Care Measure (PCPCM).

RESULTS

Initial ratings of care quality were high (mean baseline PCPCM score = 3.63) and remained high on second interview (mean change in PCPCM score = -0.04, 95%CI -0.16, 0.09, P = .58) despite significant reductions in parents' ratings of access to care over time. Parents reported substantial stress, unmet social needs, and unmet healthcare needs, with 41 families (56%) ever using the practice-based SDoH program, including 16 (22%) who were new users in 2022. There was no association observed between PCPCM score and parent stress, unmet social needs, or use of SDoH services.

CONCLUSIONS

Parents' perceptions of care delivered in their child's medical home appears to be stable on repeat measurement, and independent of family context or interactions with social needs navigation services offered in the practice.

Barriers and facilitators to refugees and asylum seekers accessing non hospital based care: A mixed methods systematic review protocol

Context

Social exclusion is characterised by and represents a form of disadvantage and marginalisation of vulnerable groups of people in society, who cannot fully participate in the normal activities of daily living. People who are socially excluded such as asylum seekers and refugees have complex healthcare needs and tend to present more to the acute hospital setting as emergency presentations. Little is known about barriers and facilitators experienced by this group to accessing nonhospital based care.

Objectives

This mixed methods systematic review, will critically examine the concept of barriers and facilitators for refugees and asylum seekers to accessing non hospital based care.

Methods

This methodological review will follow the Joanna Briggs Institute guidance for conducting mixed methods reviews. The following databases will be searched: Central Medline, PubMed, Embase, CINAHL, and the Cochrane Library. Relevant grey literature will be included. Title and abstract screening, followed by full-text screening will be undertaken independently by two reviewers. The Joanna Briggs Institute extraction tool will be adapted for data extraction.

Discussion

This mixed method review will comprehensively evaluate quantitative and qualitative data, synthesise both barriers and facilitators and follow a systematic approach through establishing use of mixed methods research across asylum seekers and refugees, and how they affect accessing non-hospital based care. It will explore conceptual models of access to healthcare and how they influence these factors.

ParallelED-A novel screening and referral intervention using emergency department wait times to identify and address unmet social needs

Background

People arriving at the emergency department (ED) often have unmet health-related social needs (HRSN). We implemented an intervention that used undergraduate student volunteers to screen patients in the ED waiting room (WR) for unmet social drivers of health and subsequently referred patients to community resources.

Methods

This cross-sectional quality improvement study included patients who were approached to complete a HRSN screening questionnaire, subsequently referred to community resources, and followed up by phone from October 2021 to October 2022 in an ED WR of an academic medical center. Primary measures were the proportions of patients who had unmet HRSN and the proportions enrolled in a statewide database of social care resources-NCCARE360. Patient demographics and geospatial distribution were also assessed to better understand the population served.

Results

Our intervention reached 3297 unique patients, with 398 patients (12%) agreeing to complete screening. Of those screened, 93% were positive for at least one social need and 95% of the aforementioned were interested in receiving assistance. A total of 60% of those who screened positive were enrolled into NCCARE360. Persons identifying as female or non-Hispanic Black were disproportionately represented at a higher rate among those who screened positive for at least one social need, with food and housing insecurity emerging as the most common referral categories.

Conclusion

Our results demonstrate patients' willingness to be screened in the ED WR and a high identification of HRSN. Our findings show that idle time in the ED WR can be used to identify patients with unmet HRSN and refer them to resources.

A Systematic Review of Electronic Community Resource Referral Systems

INTRODUCTION

Community Resource Referral Systems delivered electronically through healthcare information technology systems (e.g., electronic medical records) have become more common in efforts to address patients' unmet health-related social needs. Community Resource Referral System connects patients with social supports such as food assistance, utility support, transportation, and housing. This systematic review identifies barriers and facilitators that influence the Community Resource Referral System's implementation in the U.S. by identifying and synthesizing peer-reviewed literature over a 15-year period.

METHODS

This systematic review was conducted following PRISMA guidelines. A search was conducted on five scientific databases to capture the literature published between January 2005 and December 2020. Data analysis was conducted from August 2021 to July 2022.

RESULTS

This review includes 41 articles of the 2,473 initial search results. Included literature revealed that Community Resource Referral Systems functioned to address a variety of health-related social needs and were delivered in different ways. Integrating the Community Resource Referral Systems into clinic workflows, maintenance of community-based organization inventories, and strong partnerships between clinics and community-based organizations facilitated implementation. The sensitivity of health-related social needs, technical challenges, and associated costs presented as barriers. Overall, electronic medical records-integration and automation of the referral process was reported as advantageous for the stakeholders.

DISCUSSION

This review provides information and guidance for healthcare administrators, clinicians, and researchers designing or implementing electronic Community Resource Referral Systems in the U.S. Future studies would benefit from stronger implementation science methodological approaches. Sustainable funding mechanisms for community-based organizations, clear stipulations regarding how healthcare funds can be spent on health-related social needs, and innovative governance structures that facilitate collaboration between clinics and community-based organizations are needed to promote the growth and sustainability of Community Resource Referral Systems in the U.S.

Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs

BACKGROUND

Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs.

METHODS

Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams.

RESULTS

108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%-60%; p=0.045) and declined for the proxy comparison (61%-42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams.

CONCLUSIONS

Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.

A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities

BACKGROUND

Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or 'race'-related health inequities.

METHODS

A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated.

RESULTS

Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a 'hybrid' framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation.

CONCLUSIONS

This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

Learning Clinical Judgments With a Lens of Inclusivity

ABSTRACT

To prepare practice-ready graduates and promote NCLEX® success, many schools of nursing have adopted a clinical judgment model (CJM) to provide a framework for their curriculum and teaching strategies. Missing from most CJMs are clear principles of justice, equity, diversity, and inclusion (JEDI), imperative to prepare a nursing workforce to care holistically for diverse populations. This article describes the curriculum integration of an adapted model with added JEDI principles. By intentionally integrating the language and understanding of a CJM with JEDI principles, nurse educators can promote the clinical judgment development necessary to prepare graduates to care for diverse populations.

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.

"Addressing the bigger picture": A qualitative study of internal medicine patients' perspectives on social needs data collection and use

BACKGROUND

There is increasing interest in collecting sociodemographic and social needs data in hospital settings to inform patient care and health equity. However, few studies have examined inpatients' views on this data collection and what should be done to address social needs. This study describes internal medicine inpatients' perspectives on the collection and use of sociodemographic and social needs information.

METHODS

A qualitative interpretive description methodology was used. Semi-structured interviews were conducted with 18 patients admitted to a large academic hospital in Toronto, Canada. Participants were recruited using maximum variation sampling for diverse genders, races, and those with and without social needs. Interviews were coded using a predominantly inductive approach and a thematic analysis was conducted.

RESULTS

Patients expressed that sociodemographic and social needs data collection is important to offer actionable solutions to address their needs. Patients described a gap between their ideal care which would attend to social needs, versus the reality that hospital-based teams are faced with competing priorities and pressures that make it unfeasible to provide such care. They also believed that this data collection could facilitate more holistic, integrated care. Patients conveyed a need to have a trusting and transparent relationship with their provider to alleviate concerns surrounding bias, discrimination, and confidentiality. Lastly, they indicated that sociodemographic and social needs data could be useful to inform care, support research to inspire social change, and assist them with navigating community resources or creating in-hospital programs to address unmet social needs.

CONCLUSIONS

While the collection of sociodemographic and social needs information in hospital settings is generally acceptable, there were varied views on whether hospital staff should intervene, as their priority is medical care. The results can inform the implementation of social data collection and interventions in hospital settings.

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.

Implementation Fidelity of Chatbot Screening for Social Needs: Acceptability, Feasibility, Appropriateness

OBJECTIVES

Patient and provider-facing screening tools for social determinants of health have been explored in a variety of contexts; however, effective screening and resource referral remain challenging, and less is known about how patients perceive chatbots as potential social needs screening tools. We investigated patient perceptions of a chatbot for social needs screening using three implementation outcome measures: acceptability, feasibility, and appropriateness.

METHODS

We implemented a chatbot for social needs screening at one large public hospital emergency department (ED) and used concurrent triangulation to assess perceptions of the chatbot use for screening. A total of 350 ED visitors completed the social needs screening and rated the chatbot on implementation outcome measures, and 22 participants engaged in follow-up phone interviews.

RESULTS

The screened participants ranged in age from 18 to 90 years old and were diverse in race/ethnicity, education, and insurance status. Participants (n = 350) rated the chatbot as an acceptable, feasible, and appropriate way of screening. Through interviews (n = 22), participants explained that the chatbot was a responsive, private, easy to use, efficient, and comfortable channel to report social needs in the ED, but wanted more information on data use and more support in accessing resources.

CONCLUSION

In this study, we deployed a chatbot for social needs screening in a real-world context and found patients perceived the chatbot to be an acceptable, feasible, and appropriate modality for social needs screening. Findings suggest that chatbots are a promising modality for social needs screening and can successfully engage a large, diverse patient population in the ED. This is significant, as it suggests that chatbots could facilitate a screening process that ultimately connects patients to care for social needs, improving health and well-being for members of vulnerable patient populations.

Creating a Primary Care Track in Prelicensure Nursing Education

BACKGROUND

RNs practicing in primary care (PC) increase access to health care and contribute to better patient outcomes and cost savings, yet undergraduate nursing education traditionally focuses on disease-oriented care. This article describes a curricular track for infusing PC prelicensure programs.

METHOD

PC content is threaded across four semesters with targeted assignments and clinical experiences. Providing clinical immersion experiences with practicing RNs as preceptors in community and PC settings is a key component of this initiative.

RESULTS

Student feedback has been favorable. Students stated they gained insight to the role of RNs in PC through class assignments and clinical rotations. Graduating seniors were offered employment in PC settings where they completed their practicum clinical rotations.

CONCLUSION

The PC track contributes to building a nursing workforce to meet health care demands and promote health equity. Nurse educators interested in infusing PC content throughout the curriculum can adapt this model for all student populations. [J Nurs Educ. 2023;62(3):171-174.].

Barriers and facilitators to refugees, asylum seekers and people experiencing homelessness accessing non hospital based care: A mixed methods systematic review protocol

Context: Social exclusion is characterised by and represents a form of disadvantage and marginalisation of vulnerable groups of people in society, who cannot fully participate in the normal activities of daily living.  Socially excluded groups consist of, but are not limited to the following groups: people experiencing homelessness, asylum seekers and refugees.  People from socially excluded groups have complex healthcare needs including infectious and non-communicable diseases. People from socially excluded groups tend to present more to the acute hospital setting as emergency presentations.  Little is known about barriers and facilitators experienced by these groups to accessing non hospital based care. Objectives: This mixed methods systematic review, will critically examine the concept of barriers and facilitators for refugees, asylum seekers and people experiencing homelessness, to accessing non hospital based care. Methods:  This methodological review will follow the Joanna Briggs Institute guidance for conducting mixed methods reviews.  The following databases will be searched: Central Medline, PubMed, Embase, CINAHL, and the Cochrane Library. Relevant grey literature will be included. Title and abstract screening, followed by full-text screening will be undertaken independently by two reviewers. The Joanna Briggs Institute extraction tool will be adapted for data extraction.   Discussion: This mixed method review will comprehensively evaluate quantitative and qualitative data, synthesise both barriers and facilitators and follow a systematic approach through establishing use of mixed methods research across a number of marginalised groups, and how they affect accessing non hospital based care.   It will explore conceptual models of access to healthcare and how they influence these factors.

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.

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.