How Workflow Factors Sway Social Determinants of Health Screening Rates

Primary care providers looking to increase their rates of social determinants of health screenings might consider having advanced practice providers administer them, among other factors, according to a JAMA Network Open study.

The study, completed by experts at the University of South Carolina School of Medicine and Arnold School of Public Health, looked at the features that influence whether a patient completes an SDOH screening in the primary care setting, helping to flag workflow details that could help increase completion rates.

“Health systems are increasingly engaging in SDOH screening,” the researchers wrote in the study’s introduction. “Although such screening can potentially improve health outcomes and reduce health care use, there is limited peer-reviewed evidence incorporating patient and clinician or care team characteristics and perspectives when describing early screening initiatives.”

SDOH screenings can be effective at identifying which social factors patients experience and equip providers with the information necessary to make a social services referral. However, these screenings don’t always happen, whether it be because the provider does not administer the screen or because the patient does not complete it.

This assessment looked at SDOH screenings during primary care visits between February and May 2022, plus care team member and patient interviews, to suss out different factors that increased or decreased SDOH screening completion.

There were nearly 80,000 primary care visits at practices administering SDOH screening, with around 70 percent of visits with an SDOH screen happening with a doctor and 16.5 percent with a nurse practitioner. In 95 percent of the visits, none of the SDOH questions were answered, while in 4 percent, all of the questions were answered.

So, what influenced whether the SDOH screenings were completed?

Foremost, it was who conducted the screening. The researchers said that when a physician assistant administered an SDOH screening with a patient, that screening was more likely to be completed than when a medical doctor or nurse practitioner administered it.

“Clinician type could be serving as a proxy for visit type as our data set did not include visit reason,” the researchers said. “Consistent with previous studies, our interview-based findings suggest that clinicians faced an additional time burden from incorporating SDOH screening, which they perceived to affect care provision.”

In other words, SDOH screenings administered during doctor-led visits may not have been completed because the doctor was seeing to a higher-acuity visit and did not have time to complete the screen. Screenings may have been completed with PAs, who may have been seeing to a lower-acuity visit or even a well-visit.

Next, the researchers observed lower screening rates for uninsured patients or patients on AccessHealth, a South Carolina program designed to connect low-income patients with affordable care.

This is an essential finding, the research team pointed out, because these patients are more likely to experience adverse SDOH than those on other payer plans. Future research should look into how to increase SDOH screening rates among this population and whether this population completes SDOH screenings in other settings.

Surprisingly, there was little association between SDOH screening completion and patient demographics. This finding counters the notion of risk-stratifying SDOH screening and supports universal implementation of SDOH screening.

Finally, the researchers observed a link between screener length and screener completion, with questions toward the end of the survey being less likely to be completed. During clinician interviews, the researchers found that long length and redundant questions may dissuade patient engagement.

“Although there is no consensus on screener length, existing tools range from 6 to 23 questions,” the researchers explained. “Generally, short-form surveys are more acceptable to patients. Notably, patients did not express the same concerns as clinicians about survey length or repetitiveness.”

During qualitative interviews, patients and providers alike stressed the importance of a strong patient-provider relationship. When SDOH screeners broached more sensitive topics, experts observed a higher rate of skipped questions or untruthful answers. While healthcare professionals should not force answers when screeners reach sensitive topics, they should focus on relationship-building to help patients feel comfortable enough to discuss these topics.

There researchers noted that there are a few unexplored areas that could shape SDOH screening uptake, including the use of standardized question phrasing to explain the rationale behind SDOH screening and the best location or visit type for screening. Future research should look into these factors, plus the way the perceived ability to follow up on flagged SDOH concerns sways patient engagement.