Considerations for Social Determinants of Health Screening Design

Assessing SDOH screening tools

As part of designing SDOH screening surveys, organization leaders need to determine the best tools on which to host the surveys. These tools largely fall into two buckets: paper-based forms and digital surveys.

Paper-based forms might be mailed out to patients before their appointments to be submitted upon check-in, or patients may complete the forms in the waiting room before their appointment begins. Healthcare organizations should clarify to patients whether they should arrive early to complete the survey.

Paper-based forms are simple and may serve organizations well as they get started with SDOH program pilots. They are a low- or no-cost investment, which can help organizations just beginning their SDOH journeys.

“Paper was really a fantastic way to start,” Emily Fletcher, MPH, director of Social and Clinical Care Integration at the Iowa-based MercyOne, said in a previous interview about the organization's SDOH screening journey.

“It allowed us to make changes to the screening form,” she added. “It allowed us to look at different opportunities within the clinic settings as to where to actually implement the screens. Is it asking patients during registration? Is it integrating it within the rooming process with the nurse?”

That said, there are some cons to using paper-based forms. Perhaps most salient, paper-based forms do not seamlessly integrate into other clinic or hospital technologies like the EHR. A healthcare professional would need to document responses into the EHR, which can be arduous and prone to human error.

Some organizations are investing in digital SDOH screening tools, with most prioritizing EHR integration to streamline provider workloads. Other tech considerations include having an opt-in screening survey, which gives patients a sense of control and autonomy during what can feel like an invasive or probing screening.

Organizations should also consider tools that allow them to outline their commitment to SDOH and explain the purpose behind the screening form. That explanation should also outline the resources the organization has at its disposal to address SDOH needs.

Determining SDOH of focus

After selecting how they will deploy SDOH screening surveys, healthcare organizations need to determine the actual content of the surveys. Which questions will the surveys ask? Which SDOH is the organization trying to learn about and uncover?

Focusing on social determinants of health for which organizations have an immediate, tangible solution is paramount. It can be frustrating for both patient and provider—and it can damage patient trust—for a social need to arise and hear there is no way to fix it.

Healthcare organizations should assess which community health partnerships it already has, or it can efficiently build, and then tailor questions for that. For example, if a healthcare organization has inroads with homeless shelters and affordable housing groups, with food pantries, and with a legal team, its SDOH screening should focus on housing security, food security, and legal needs.

Conversely, it would not make sense to screen for transportation needs if the organization does not have a rideshare or non-emergency medical transportation partnership.

“It is really important to make sure that when people are in situations where they have many unmet social needs, we have to just start somewhere,” Kara Odom Walker, MD, MPH, MSHS, chief population health officer at Nemours Children's Health, advised in a previous interview.

“One of the identified needs that rises to the top was also food insecurity,” she added as a second example. “That's one where we have a much clearer path. We have partners in the community that can provide food services.”

After a healthcare organization has been offering SDOH screening for a while, it may anecdotally observe a few common social needs for which it does not currently have resources. Those needs may also arise through a community health needs assessment (CHNA).

Organizations can respond by doing community outreach and building out the relationships necessary to integrate that new social service. From there, the organization may consider adding questions about that need to its SDOH screening survey.

In addition to screening for specific social needs, organizations need to consider the verbiage and actual flow of the survey. Particularly, they may consider:

• Patient health literacy levels
• Software on which the survey is hosted
• Other language options

This may not be a one-size-fits-all approach. For one organization, ensuring it has both paper-based and digital screenings may be key, while it can mostly offer the surveys in English and Spanish. In another region, organizations may need to consider tools that offer screenings in several different languages but knows their patient populations are highly digitally engaged.

In addition to reviewing organization data to understand population demographics, organizations may consider tapping their patient advisory council to guide implementation.

Patient-provider communication about SDOH screening

SDOH screening can be challenging because patients aren’t always comfortable discussing often sensitive personal information that does not directly pertain to their health. It could be difficult for patients to admit they are housing insecure, for example.

This is even more salient for guardians accompanying kids to the pediatrician.

In 2019, researchers from Public Agenda and United Hospital Fund reported that although parents can see a throughline between child health and some SDOH, they are reticent to discuss some of those topics. Particularly, parents or guardians were worried about discussing their own mental health, legal issues, or domestic problems, especially if they did not have an established rapport with the pediatrician.

Parents and guardians were particularly concerned they’d be reported to child protective services if they mentioned a problem to the pediatrician.

Healthcare providers need to use their patient-provider communication skills to engender trust with patients and make patients comfortable discussing social determinants of health.

The Public Agenda and UHF researchers recommended providers clarify the importance of SDOH and state why they are raising this discussion. Additionally, they should continually reaffirm confidentiality, be transparent about topics that could trigger a report to child protective services, and be judicious about not raising SDOH discussions in front of child patients.

Similar considerations can apply during adult care interactions. For example, adults also need to know why their provider is raising the topic of food security in order to feel comfortable discussing the topic. Adults also benefit from knowing that there would be a solution to the SDOH problem they report—which is why it’s important organizations carefully select which SDOH they include in a screening survey, as outlined above.

At the end of the day, patients need to know that they don’t have to complete a screening; it is their right to keep that information private until they are comfortable with their clinician, according to Alisahah Cole, MD, system vice president of population health at CommonSpirit Health.

“When we really start thinking through how to start asking patients these questions, being thoughtful about the empathetic inquiry mindset, and knowing that even though we need to know this information, we recognize that although we need to know this information now to better take care of patients, this is new,” Cole explained during her keynote address at the 2021 Xtelligent Healthcare Media Patient Experience virtual event. “This is not just new for our providers, but it's also new for the patients.”

For clinical practice and patient-provider communication, Cole recommended three guiding principles. Foremost, clinicians must tell patients that they are not required to complete a social determinants of health screening.

Next, clinicians must assure patients they don’t have to answer a particular question if they don’t want to. And relatedly, patients should know that they can stop the screening at any time. After all, social determinants of health are sensitive issues, and patients may not feel safe disclosing this type of information to their medical providers.