Research: Even When SDOH Screening Occurs, At-Risk Patients Aren’t Captured

In recently revealed study findings, Boston Medical Center (BMC) researchers found that only a fraction of patients at risk of having their utilities shut off were identified through social determinants of health (SDOH) screening.

Published in The Journal of Ambulatory Care Management, the research showed that among the patients who received a utility protection letter in 2018, 70 percent were screened for SDOH and only 16 percent screened positive for difficulty paying their utility bills.

The researchers stressed that preventing utility shut-off is vital to maintaining patients' health, which is why most states in the U.S. have laws prohibiting or delaying utility companies from terminating service to low-income households when occupants present a medical letter confirming a household member has a chronic serious illness.

In January 2018, Boston Medical Center implemented an electronic health record (EHR)-based SDOH screening and referral program, which identifies eight domains of potentially unmet SDOH needs: housing and food insecurity, inability to afford medications, utilities or transportation, need for employment or education, and difficulty taking care of children or other family members.

However, the researchers noted, there are several reasons why patients may not be identified for utilities insecurity. Difficulty paying utility bills may be a seasonal phenomenon, meaning patients screened in warmer months may not identify this need as they would in the winter when heat is a necessity, especially in Boston.

What’s more, screening for SDOH also takes place at medical appointments, and patients in precarious social circumstances may be less likely to attend visits and therefore may not get screened. Patients may also feel stigmatized by SDOH screening, or may not report difficulty paying for utilities if they are already receiving assistance, according to the researchers.

To this end, 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. However, practices serving more economically disadvantaged populations report screening at higher rates, as did those organizations participating in bundled payments, primary care improvement models, and Medicaid accountable care organizations (ACOs).

In a recent Healthcare Innovation story on SDOH screening, Jacob Reider, M.D., CEO of the Alliance for Better Health, said the lack of an adequate infrastructure that would allow for appropriate action to take place is the reason why SDOH screening rates are so low in many provider organizations.

For example, if a system was in place in which a provider could easily connect a patient with a social worker who worked in the same building, that would result in an uptick of screening rates. Similarly, if the system made it easy for a physician to send a referral out to the network—say for a food security issue—the network would pick it up, leading to that food security challenge being addressed. But because the current infrastructure doesn’t allow for that type of seamless coordination, SDOH screening rates remain low, Reider believes.

Researchers also analyzed characteristics of adult patients at BMC, a safety-net hospital, who received a utility shut-off protection letter between 2009 and 2018. During the study period, nearly 3,000 unique adult patients received a utility letter. Looking at the demographics of those receiving the letter, two-thirds were women, most were English-speaking, and the average age of the person receiving the letter was 56 years. Two thirds of the patients were non-Hispanic black and 75 percent had government insurance. Overall, these patients had high levels of medical and behavioral health comorbidities.

"Patients experiencing difficulty paying utility bills may not be detected by systems of care that screen for SDOH, and this is concerning for at-risk populations," said Karen Lasser, M.D., a general internist at BMC and professor at Boston University Schools of Medicine and Public Health. "This research calls for better approaches to identify those needing assistance, to ensure better health outcomes for all patients."