By Emma Opthof, Center for Health Care Strategies
The health care sector continues to ponder its role in addressing social needs. Providers in clinical settings have increasingly been screening for social risk factors, but the extent of screening in these settings is not fully understood. To explore this issue, the Social Interventions Research and Evaluation Network (SIREN), an initiative of the University of California, San Francisco (UCSF), recently published a report synthesizing the peer-reviewed literature and knowledge gaps on social screening practices in health care. The report examines the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.
The Better Care Playbook spoke with Emilia De Marchis, MD, MAS, lead author of the SIREN report and assistant professor at the Department of Family and Community Medicine, UCSF, to learn about the state of social needs screening and implications for people with complex needs and the providers that care for them.
How can social needs screenings benefit people with complex needs?
From our report, we found that patients recognize that their health care team knowing about their social risks can improve their care and the relationships with their providers. Providers also feel that screening can help them better contextualize the care that they're providing to patients. All of this is in line with the 2019 NASEM report on integrating social and medical care that calls for that awareness and ability to then provide adjustment and care based on patient social risks. Not a lot of the literature we found focused on people with complex needs, but I think it stands to reason that the social context is even more important to recognize in this population and helps providers to adjust and tailor care. Screening itself can have a positive effect on social needs beyond the assistance that can be provided.
You describe how there is a “thousand flowers blooming” approach to social needs screening. What do we know about how often social needs screening is taking place, which care settings are implementing these screenings, and what screening tools and approaches are used?
One section of the report is dedicated to understanding the prevalence of screening, where we looked at surveys across the health care sector to try to find out who's screening and for what. Those studies are challenging because one, many had a low overall response rate from organizations. And two, while these surveys give us a little bit of information about the percentage of organizations that are screening, they don’t provide us information about how many patients are actually getting screened. We saw differences in the survey responses across various studies, ranging from 20 to 100 percent of organizations saying that they were conducting these screenings.
It seems like across the board that different settings are looking at ways to screen and collect this information. From the peer-reviewed articles, we saw a lot of screening activity in primary care emergency departments and both pediatric and adult and family medicine settings, with a growing number of specialty settings including oncology, dermatology, and hematology.
In terms of how they're deciding to implement and what tools to select and approaches, this also really varies. A lot of organizations are looking at existing tools, such as the Accountable Health Communities Health-Related Social Needs Screening Tool and the PRAPARE tool, which are available in other languages and can be integrated with other screening tools. But then in much of the literature, we're also seeing that organizations are actually adapting these tools based on leadership preferences, the implementation team, or pilot feedback from their providers and/or patients about questions that aren't included that they want to ask or questions that were included that weren't as relevant. This tailoring of tools can make it challenging to pool data across studies.
What are some key takeaways about what patients and caregivers think about social needs screenings and potential follow-up assistance?
We focused on the perceived acceptability of screening — how patients and their caregivers responded to being screened. There were only a limited number of studies, but overall, most found a high acceptability of screening. An important opportunity for future research is understanding if and how acceptability differs across patient populations, as there were mixed findings from studies on how it may differ by patient race, ethnicity, and/or gender.
We did find that there's been some work on improving how we frame screening, introduce it to patients and their caregivers, and normalize the process and efforts to ensure data privacy, which can increase patient and caregiver acceptability. So, there's growing evidence in how we can take strides to improve the patient and caregiver experience, but still a lot for us to learn about how different patient populations may respond differently or similarly to screening.
This review did not specifically focus on how patients perceive potential assistance, but in a study that we conducted through SIREN across multiple sites, we found that patients didn't expect their health care team to resolve their social risks. There's also literature on provider experiences of discomfort with not being able to provide assistance and patient experiences of not having that assistance always being successful through the health care team or on the social services side. There is a need to explore more what the patients and caregivers actually do want from the health care team in terms of the follow up after screening and how we can best align and collaborate with community organizations to assist patients with their needs. SIREN sponsored a special issue supplement in the American Journal of Preventative Medicine that includes six research studies looking at different aspects of patient interest in assistance.
When implementing social needs screening programs, what partnerships are needed to connect patients to resources?
We came across several articles that discuss the importance of connecting with the community and existing community-based organizations (CBOs). Finding out what the community needs and wants, what resources already exists in the community, and how to partner with CBOs so that you're not duplicating efforts or referring patients to resources that they’re not eligible for or don't exist is all really important pre-work to help identify gaps and better understand whether patients are receiving the assistance they need or not. There's also a growing exploration of and continued unknowns with IT partnerships and platforms that may help to facilitate assistance and communication with organizations. We do include some links in the review that can help organizations that are starting to do this work understand growing best practices and available implementation guides.
How can understanding the evidence on social needs screening help organizations advance health equity?
One of the main goals of this review was to understand how screenings impact health equity. Overall, we found that there's very little research that could help us answer this question directly. Organizations should recognize the importance of tracking what they're doing related to equity — looking at who's being screened and how that differs by different patient populations, especially patients with complex needs. We need to be able to stratify to see how the screening and referral efforts are affecting different patient populations. Most importantly, we want to avoid further marginalizing patients and caregivers who are already experiencing social and economic marginalization. I think this review is hopefully a way for us to understand the importance of continuing and further diving into this work, because there was some mixed evidence in terms of how screening might impact equity for different patient populations, based on preferred languages or experiences of marginalization.
Overall, it is important to have an equity lens when planning social screening processes and to maintain it during implementation and evaluation.
What are the key takeaways for health care organizations and others who are leading complex care initiatives?
My big hope is that organizations see this review as a call to rigorously study these initiatives, which I recognize takes resources. But hopefully they can partner with other organizations, or at least be collecting the data in a way that they can stratify by different patient populations and see who the screening and referral is reaching, how patients and providers are perceiving screenings, and if it is impacting their care and long-term outcomes.
There’s a lot of excitement and energy around social screening — the policy initiatives and the support from organizations is really exciting. Our hope is that it's channeled in a way that's coupled with the necessary resources, including supports for health care teams to adapt their workflows to screening in a way that doesn't contribute to further burnout as well as improving the patient care experience, while critically looking at the data along the way. I hope we can harness all this energy around social screening in a way to better understand how to best do this work.