Why Aren’t More Providers Screening Patients for SDOH?
There has been real momentum around incorporating social determinants of health (SDOH) data into providers’ workflows, with news of new investments and collaborations between healthcare players and community-based organizations becoming a common occurrence.
More recently, financial investments into SDOH have also increased. In November, for instance, 14 of the nation’s largest health systems announced a commitment of $700 million toward community-based initiatives aimed at addressing the economic and environmental drivers behind a widening disparity in health outcomes. Most of those dollars will go to providing affordable housing with each participating health system submitting annual data to provide metrics to track their activities.
Indeed, there is growing evidence that a significant amount—upwards of 70 percent, according to some research—of a person’s health outcomes is driven by SDOH factors has led traditional industry stakeholders to look beyond just clinical settings. At the same time, a slew of challenges still remain, starting with a very fundamental one: there appears to be little consensus about responsibility for addressing social needs or the best approaches to the problem.
A study published last fall in JAMA Open Network, inclusive of responses from more than 2,100 physician practices and nearly 800 hospitals across the country, found that just one-quarter of U.S. hospitals and 16 percent of physician practices self-report screening patients for social determinants of health such as food, housing, transportation, utilities, and interpersonal violence needs.
Researchers from University of California, Berkeley, Dartmouth, and the University of North Carolina noted, “Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a necessary first step to addressing these needs, yet little is known about the prevalence of screening.”
What’s more, the study’s findings suggested that most U.S. physician practices and hospitals do not report screening patients for key social needs, and it appears that practices serving more economically disadvantaged populations report screening at higher rates. Further, federally qualified health centers (FQHCs) and physician practices participating in bundled payments, primary care improvement models, and Medicaid accountable care organizations (ACOs) screened more than other hospitals, and academic medical centers screened more than other practices, according to the findings.
While it might be befuddling on the surface that healthcare stakeholders have increasingly recognized the importance of addressing SDOH, yet don’t exactly know how to take action, Jacob Reider, M.D., CEO of the Alliance for Better Health, is not at all surprised by the study’s findings. “We are not screening patients for SDOH because we don’t have adequate infrastructure from which we can take action,” says Reider, the former chief medical officer and deputy director of the Office of the National Coordinator of Health IT (ONC).
Reider, whose Alliance for Better Health organization recently created a subsidiary entity—called Healthy Alliance Independent Practice Association (IPA), which will bring together medical providers and community-based organizations to address SDOH—notes that one of the core principles of screening is to look for something in the absence of knowledge that the thing is there. For example, physicians will screen for cholesterol as there’s good evidence that checking those levels can help ensure a patient is healthy; if the numbers are too high, “I can do something about it once I recognize the problem that I was previously unaware of,” Reider says.
But it’s not as simple with SDOH, he contends. “[Let’s say] I’m a typical family doctor, you are in my office, and I ask if you have challenges with knowing when you or your kids are going to get their next meal. In most primary care practices, if you were to answer yes, I would not have the foggiest idea of what to do. Let me reach for a sticky pad and give you a phone number of a nearby food pantry. That’s pretty much all I know how to do.”
Reider’s key point is that knowing what action to take—and having the right infrastructure in place that allows one to take such action—are the essential components and precedents to any good screening program. “So it’s no surprise that such a small number of acute care facilities and primary care facilities are screening for SDOH,” he says, referring to the research in JAMA Open Network.
There’s also another core finding from the study that Reider believes is important: that FQHCs and practices participating in value-based care programs, as well as those serving more economically underserved patients, report screening at higher rates. “There’s an obvious reason for that,” Reider says. “These [organizations] are connected to community-based organizations and resources, and many of them have social workers on site and behavioral health providers in the same facility. So when you are screening for food security challenges, for instance, [you can] walk you down the hall and meet a social worker who will help connect you with the services you need.”
Meanwhile, the last component—taking action—is absent from 95 percent of primary care practices in the U.S., Reider attests. “There is no infrastructure in the communities and no knowledge in the practice. And I would actually argue that [physicians] shouldn’t know these things. They shouldn’t have all the food pantries, behavioral health providers and domestic violence shelters memorized,” he says. Yet, as a system, he adds, doing the right thing should also be the easy thing to do. The system should allow physicians and others who recognize SDOH needs to send a referral out to the network—say for a food security issue—and the network would pick it up, leading to that food security challenge being addressed, Reider explained.
Ultimately, he believes that the SDOH screening rates would be at 90 percent or above—as opposed to less than 25 percent—if “we had the action—something that was available and easy—with the community infrastructure.”
Which policy levers can be pulled?
On the policy front, Reider contends there are two primary domains where state and federal governments “could engage to reduce the friction with which we broaden the scope of these [SDOH] programs.” One is to think about what Reider calls “convening trusted brokers in communities.” Here, he points out that when community health networks are built, they need to be developed in a horizontal manner rather than a vertical one.
For example, if one health system or health plan tries to implement an SDOH program in a community, then it could get to a point in which just one group of individuals has access to a set of resources rather than the entire community. “That does not serve a community well. You’d hate to a see a line at a food pantry where the members of a certain health plan are ahead of the rest of the community in line. That doesn’t make sense,” Reider says.
Nor does it make much sense that certain organizations would receive funding only for some SDOH issues—say one health plan wants to invest in food, another in transportation, and another in housing—which ultimately leads to a good housing program for certain folks, a good transportation assistance program for others, and now for the provider, he or she has to then ask patients who their health plan is, explains Reider. “That’s not something I should be in a position of asking when I’m trying to address the very basic SDOH.”
A solution to this challenge, he contends, is to create a network of networks that includes a framework for how to pay for these programs. A model could have a “trusted broker” or “network coordinator”—previously written about in Health Affairs by health policy researcher Len Nichols—sitting in the middle between health plans and community-based organizations. This liaison would broker a relationship between not just one health plan, but all the health plans in the region, thereby producing a “horizontal investment in which all the community-based organizations understand what they are being paid for, the community is supportive, and the health plans are investing equally by attribution,” says Reider.
The second domain is interoperability, he says, noting that EHR [electronic health record] systems need to talk to each other so that a physician can send a referral into the network, the network can catch the referral, and then it could be deployed to the community-based organization. And most importantly, he adds, “We need to have the [community organization] address the issue and give feedback, so that the loop is closed. This way, the provider can see if the issue has been [properly] addressed or not.”
At Reider’s organization, staffers in the office are continuously monitoring a dashboard looking for real-time data that shows if loops have been closed or not. “Either issues are closed or they’re not. And when they aren’t, my staff digs in to find out why. Of course, our goal is to have zero people fall through the cracks,” he says.
