Social determinants of health (SDOH) correlate directly with an individual's overall health. Primary care providers (PCPs) and hospitals help patients meet their basic health care needs, but what if a patient has other needs beyond health care, like homelessness? Luckily, there are interventions and strategies health care providers and hospitals can use to direct patients to the proper services to meet their social needs.
Providers are in the driver’s seat.
Some providers have begun assessing patients’ access to social services to improve health outcomes. However, some providers may find this to be awkward and challenging. After all, some patients may not want to admit that they are having trouble feeding their families or making consistent payments on their homes. Providers must have a systematic and sensitive process for assessing patients’ social needs and connecting them with the appropriate resources.
Clinics have begun implementing screening tools that allow providers to target specific community-based organizations (CBOs) and connect them to the populations that would most benefit from their services. However, most providers are not reimbursed for these screenings, causing inconsistent usage of the screening tools. Some health care organizations are incentivizing providers to assess patients’ SDOH needs. Despite these incentives, most providers still do not see the benefit in assessing SDOH if they receive nothing in return.
While some electronic health record (EHR) systems make it easier for providers to access patients’ health information, most EHRs do not document SDOH. This inconsistent collection and documentation of patient data make it even harder for providers to connect patients to the appropriate services.
Providers with access to EHRs that can screen for SDOH are experiencing an entirely different problem: the cost of care that CBOs charge. Patients may be unable to afford to pay for their doctor’s appointments, much less an appointment with another organization to meet their other needs. Due to a larger number of referrals from providers, some CBOs have also begun to escalate their costs of care, causing even more of a financial burden for patients. To ease the high costs and provide the best patient care, providers should work with their local CBOs and partners to optimize programs and services.
Despite all these obstacles, however, there are still strategies providers can use to integrate SDOH into their care. This implementation has four steps:
- Collect and organize SDOH data. Providers must collect population-based and individual patient data to have the most accurate understanding of how SDOH affect the local community. The screening can be done in person by asking the patient about issues they are having in a sensitive and caring way. This may alleviate the anxiety patients feel revealing this information to their provider and allow them to open up about the issues they need help with. Screening can also be done electronically via EHR systems, as mentioned before.
- Integrate SDOH data into practice. The most effective way to integrate data into practice is to collect, organize and share the patient data collected via EHRs. EHRs provide quick access to patient data, which can help providers refer patients to the right services more quickly if assessed at the right time. Understanding the data to better refer patients is also essential.
- Develop response strategies. Some EHRs include reminders and alerts to notify providers of the best services to recommend for patients, depending on their needs. Whether providers use EHRs or not, it is essential to have a quick, non-biased strategy for responding to patients’ needs. Removing bias can help reduce the social stigmas that surround SDOH.
- Connect patients to appropriate social services. Referring patients to the correct social services has proven to improve patients' health care and lower costs. However, it can be challenging for some patients to navigate the sea of social services that exist. They may need a provider to contact CBOs on their behalf. Resources like findhelp.org allow for quick and easy access to a list of local social services. All patients have to do is type in their zip code and select what service they need. The more providers familiarize themselves with local CBOs and other resources, the quicker patients can receive help.
Hospitals can help drive change, too.
Hospitals are also in a unique position to address patients' SDOH needs. However, instead of trialing specific initiatives that connect patients to CBOs, hospitals primarily focus on organizing other clinics’ intervention results. Because the costs to implement intervention techniques are so variable, hospitals should partner with local CBOs or health care organizations to split expenses and drive innovative solutions to address SDOH, not just gather data for others.
To address SDOH, hospitals should implement community health assessments (now a requirement now for nonprofit hospitals through the Affordable Care Act) that can narrow down the specific needs that should be addressed in their communities. Hospitals must recognize that SDOH can vary from person to person and that a blanket or generic intervention technique should not be applied to specific patients. Instead, hospitals should consider identifying sub-populations within their communities and the interventions that would most benefit each sub-population. This allows hospitals to focus on primarily impactful areas of need while covering more ground.
The American Hospital Association (AHA), Health Research & Education Trust (HRET) and Association for Community Health Improvement (ACHI) provide SDOH guides that include innovative and effective strategies for reducing food insecurity, housing instability and transportation challenges that rural populations often face. These guides can provide hospitals with proven techniques to address SDOH in their communities.
Evaluating and addressing SDOH is critical in improving the overall health of our community. Providers and hospitals are in the best position to ensure that patients receive the help they need. Through proper screening, quick response and fostered connections with local CBOs, our communities can be one step closer to eliminating barriers preventing rural families from receiving the help they need.
