Social Determinants of Health
About
Social Determinants of Health (SDoH) are economic and societal factors that affect health outcomes individually and systemically. They include the physical environment in which someone lives and works, the education they can access, or the availability and affordability of healthy food in their area. SDoH have a major impact on health, both directly and indirectly. However, SDoH are not as easily or consistently documented by providers as other factors, such as medical history.
From March 2020 through June 2021, we completed six activities in this project to evaluate the current SDoH data collection practices across Parkview Health and formulated recommendations to Parkview Health about how to standardize.
Our research questions included:
- How to best collect and curate data related to SDOH?
- What are provider perceptions about SDOH screening, responding, referring and information needs?
- What are patient perceptions about disclosure of their SDOH screening information and expectations of providers to address and report needs?
- What are implementation considerations related to SDOH screening for workflow, training, ease of referrals, data storage, and providing useful information at point of care?
Stakeholder focus groups
We conducted sessions of stakeholders across 21 service lines at Parkview Health (N=34) where we collected all SDoH screening tools and processes currently in place. We found variation in the screening process and in the process for addressing SDoH needs. Overall, there were 10 SDoH screening tools, which included a total of 131 SDoH screening questions. Thirty-eight of the identified questions were shared across multiple tools. Only 34 questions had been validated by other research. The work culminated in a database of questions for all SDoH domains, including where they were used in the health system and by whom (what roles), reading level of the question, and if the question had been validated.
Retrospective chart review
We examined historical SDoH data collected at Parkview in the Population Health department, where the process of collecting SDoH has been formalized for several years. Our goal was to quantify the rates of screening and positivity for the eight domains of SDoH. We analyzed SDoH data collected on 22,453 unique patients who were seen between 1/1/2016 to 7/17/20. We found 42% of patients had been screened at least one time and, of those screened, 62% were positive for an unmet SDoH need. Financial insecurity, emotional health and social support were the most prevalent needs reported. Screening for financial insecurity (89%), social support (88%), and transportation (94%) occurred at the highest rates. Health literacy (28%) and domestic violence (44%) screenings occurred at the lowest rates.
Provider Interviews
We conducted interviews with 38 Parkview providers (14 service lines/ 8 clinical roles) about how SDoH data were collected and addressed. Our analysis uncovered important screening practices including triggers for screening, processes for identifying candidates to be screened, choices for time-place-form for screening, actions taken on positive screens, and perceived values of screening tools in use. Several themes specific to referring patients to resources included gaps in communication, struggles transferring responsibility to the patient or another provider, and inefficient methods of identifying and retaining a repository of patient resources. The medical record documentation process was also variable for recording the results of SDoH screening results, referrals, and follow-up.
Patient Interviews
Eighteen patients were interviewed regarding their perceptions about healthcare providers collecting social needs information and committing it to the electronic health record. Thematic analysis of these interviews revealed conflicting perceptions about timing and method of screening for social risk factors, where some preferred in-person screening while others preferred answering a questionnaire prior to an office visit. Likewise, there was mixed preference for whom within the health system should be given access to social needs documented in the medical record. The varying patient trust levels is a primary consideration in the utility of screening and usage of SDoH data.
Clinic Observations
Three days of clinical observations with five providers were completed in two clinical areas. These observations allowed us to define important considerations for the social needs screening workflow, referral process and resource repository, electronic medical record documentation process, and validation of provider interview findings.
Delphi Study
A Delphi panel of Parkview Health employees (N=58) completed multiple rounds of surveys to reach a consensus for SDoH screening questions, frequency, and mode. A set of validated questions covering all domains of SDoH was identified. Experts recommended some questions for more frequent screening. However, screening was only recommended as part of an encounter with availability of a provider to address any SDoH needs. Clinical interview or self-administered questionnaire were acceptable forms for screening.
Ongoing
The set of SDoH screening questions identified by the Delphi panel were compiled and built into the EHR as the SDoH flowsheet, which has been used for screening in additional outpatient clinic settings. Screening rates are currently monitored, and a committee meets regularly to oversee expansion of SDoH screening. We also completed observations at three departments where the SDoH flowsheet was piloted, to identify the barriers coworkers face when filling it out and assess the prevalence of such barriers.
Partners
Funding
Publications and presentations
- Kiessling, K., Iott, B., Pater, K., Toscos, T., Wagner, S. R., Gottlieb, L. M., & Veinot, T. (2022). Health informatics interventions to minimize out-of-pocket medication costs for patients: What providers want. Journal of the American Medical Informatics Association Open, 5(1). [link]
- Richards, O., Iott, B., Pater, K., Toscos, T., Wagner, S. R., Gottlieb, L. M., & Veinot, T. (2022). “It’s a mess sometimes”: Patient perspectives on provider responses to healthcare costs, and how informatics interventions can help support cost-sensitive care decisions. Journal of the American Medical Informatics Association, 29(6), 1029–1039. [link]
- Iott, B., Pater, J., Wagner, S., Toscos, T., & Veinot, T. (2020, November 14–18). Improving social determinants of health screening implementation through collaboration: Leveraging a clinical-academic partnership [Poster session]. American Medical Informatics Association Annual Symposium, Virtual.
- Iott, B., Anthony, D., Pater, J., Wagner, S., Toscos, T., & Veinot, T. (2020, July 10). Nothing new under the sun: How existing screening programs can inform the design of social determinants of health screening in health care [Poster session]. AcademyHealth, Virtual.
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