Few Physicians Screen for Social Determinants
of Health

Ricki Lewis, PhD

September 18, 2019

A minority of physician practices and hospitals screen patients for social risks, which are associated with poorer compliance, worse clinical outcomes, and higher healthcare costs, according to findings of a study published online today in JAMA Network Open.

"Do you feel safe at home?" "Can you get enough to eat?" "Do you need help with transportation?"

Many patients are familiar with such questions as part of a physical examination, and ICD-10 "Z-codes" cover the "social determinants of health" (SDoH). Code Z59.9, for example, specifies a "problem related to housing and economic circumstances, unspecified," and Z60.4 addresses "social isolation, exclusion and rejection." The media have also publicized the need to assess social factors, such as the 2018 widely-reported case of a Maryland woman found on a frigid street corner clad only in a hospital gown following her discharge from a hospital emergency department.

Taressa K. Fraze, PhD, of Dartmouth College, Hanover, New Hampshire, and colleagues examined the prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence in physician practices and hospitals. They sought to identify which clinical settings screen for SDoH and their incentives for doing so.

The researchers used self-reported data from 2190 physician practices and 739 acute care or critical access hospitals taking the 2017–2018 National Survey of Healthcare Organizations and Systems, collected from June 2017 to August 2018. They also considered data from the OneKey database, the US Census, and the American Hospital Association's annual survey.

A practice included three or more primary care physicians (family medicine, geriatrics, internal medicine, or preventive medicine specialties). Hospitals included short-term acute care and critical access hospitals, but not specialty hospitals.

Respondents were asked "Does your practice have a system in place to screen patients for food insecurity (yes/no), housing instability (yes/no), utility needs (yes/no), transportation needs (yes/no), or interpersonal violence (yes/no)?"

Only 15.6% of physician practices and 24.4% of hospitals reported screening for all five social needs, whereas 33.3% of physician practices and 8% of hospitals reported screening for no social needs.

Screening for interpersonal violence seemed to drive questioning about social needs and occurred at 74.2% of physician practices and 57.3% of hospitals.

Among the physician practices, screening rates varied by social need: 56.4% reported screening for interpersonal violence, 35.4% for transportation needs, 29.6% for food insecurity, 27.8% for housing instability, and 23.1% for utility needs.

For hospitals, 75% reported screening for interpersonal violence, 74% for transportation needs, 60.1% for housing instability, 39.8% for food insecurity, and 35.5% for utility needs.

The researchers note trends in the characteristics of the physician practices and hospitals. Practices serving more disadvantaged patients; those receiving bundled payments or using primary care improvement models such as medical homes; or those with a commercial accountable care organization contract were more likely to screen for all five social needs.

The highest screening rates were for practices in the west, followed by the south, the northeast, and the midwest. Screening rates did not differ according to rural status, practice size, inclusion of specialists, or ownership.

Although hospitals did not differ according to these factors, academic medical centers were significantly more likely to screen patients for all five social needs compared with non-academic medical centers.

The researchers identified the following barriers to asking about social needs in both physician practices and hospitals: lack of time, financial resources, and incentives. They attribute the better performance by hospitals to richer resources — including funds, staff, and technology — and the fact that hospitals routinely screen patients for transportation and housing needs to meet federal regulations.

"These new data suggest that most US physician practices and hospitals are screening patients for at least 1 social need (most often, experience with interpersonal violence), and most are not screening patients for the 5 social needs that [Centers for Medicare & Medicaid Services] has prioritized: food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence," the researchers conclude. They add that uptake of asking about social needs is "notoriously slow," with barriers high due to insufficient funding and siloed supportive organizations.

In an invited commentary, Rachel Gold, PhD, MPH, of the Kaiser Permanente Center for Health Research Northwest, Portland, Oregon, and Laura Gottlieb, MD, MPH, of the Department of Family and Community Medicine at the University of California San Francisco, cite additional barriers to screening for social needs. Healthcare providers may hesitate to adopt screening if they think that they cannot intervene to address the issues that patients bring up, or they may question the need for universal screening.

"Future research should not only elucidate barriers to the implementation of social risk screening but also surface evidence-based methods for overcoming them. These methods will likely require providing diverse implementation support strategies tailored to the needs of different health care settings," they write.

Limitations of the investigation include reliance on self-reporting; the possibility that the respondents did not report all efforts to screen for social needs at their institutions; and lack of information on how healthcare

organizations are using patients' screening results. Gold and Gottlieb also suggest that data from electronic health records and insurance claims flesh out information from surveys.

The researchers and commentators have disclosed no relevant financial relationships.

JAMA Network Open. Published online September 18, 2019. Full text, Editorial

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