Why screen for social determinants of health?
In the United States, we spend increasingly more money per capita on medical services compared to other industrialized nations, while we spend increasingly less on social services. Thus, despite medical advances and increased health care spending, underinvestment in addressing patients’ socioeconomic needs inhibits progress in achieving improvements in our nation’s health.
Social needs that contribute to health disparities have historically been a concern for public health, social service, or religious and charitable organizations. But now, in no small measure lead by those within the pediatric community, we recognize an expanded role in identifying and addressing social needs which is squarely positioned within, and not separate from, systems of health care delivery.
Innovation and advances in pediatric practice and the patient-centered medical home provide convincing evidence that screening for basic unmet social needs can facilitate successful connections with community resources, with resulting improvements in health. In addition to potential benefit to individuals, screening provides important information for healthcare systems and communities, essential to decisions regarding reimbursement rates and program development.
Okay, I’m convinced there is value in screening – what screen should I use?
Hold on there, tiger! Unfortunately, there is a lack of validated, multidimensional, comprehensive screening tools for pediatric care professionals. Truth be told, there has been wide variation in how researchers and health care organizations develop, validate, and implement tools for identifying/addressing patients’ social needs.
The lack of standardized workflows/screening tools has largely resulted in ad hoc efforts to assess patients’ social needs with varying degrees of success and validation in terms of sensitivity, specificity, or evidence that outcomes are altered. This is currently an area of tremendous flux and study, as we move along the learning curve.
Social Determinants of Health is a new priority in the fourth edition (2017) of the AAP Bright Futures Guidelines, which includes questions that explore child and family social needs in a systematic way, woven into each well child visit.
Providers may also want to become familiar with Minnesota resources for families:
The Minnesota Food HelpLine (1-888-711-1151) assesses the caller’s situation and provide solutions to their food needs.
Although Bridge to Benefits, a free online screening tool (mn.bridgetobenefits.org) developed by Children’s Defense Fund-Minnesota, does not screen for social determinants of health, it does assist in determining eligibility for federal assistance programs and tax credits. HelpLine Hours: Monday-Friday 8:30 a.m. to 4:30 p.m.
Is there any potential harm in screening, or certain care situations when it should not be undertaken?
Some pediatric practitioners have argued that screening for social needs and identifying risks and conditions that may require resources beyond the scope of clinical care, without the capacity to ensure referral and linkage to appropriate treatment, is ineffective and potentially unethical.
Others have argued that screening reveals social injustices and speaks to the important role of public health surveillance, which often lays the groundwork for programs that do not yet exist.
Most clinicians would readily agree that screening should not be performed in the context of care for an acute life-threatening event. Some would argue that primary care is the best environment for screening, but others would point out the potential value of screening in multiple other situations, including acute, in-patient, and specialty care sites.
Rigorous consideration of validation and replicability of screening needs further study, with careful consideration of how screens are delivered (verbally, by whom vs paper vs computer), which may strongly influence disclosure.
The Wilson criteria, the standard applied in the last 40 years for screening processes, has been more recently synthesized into an emerging new criteria framework may also provide some helpful guidance (see box below).
What does the future hold with regard to screening for social needs?
Clearly, continued research, innovation, and development of policies and programs is needed. Efforts that foster innovation and flexibility through the use of Accountable Care Organizations and Medicaid waivers can play an important role.
One of the biggest investments in the field is the Centers for Medicare & Medicaid Services innovation initiative of $157 million toward creation of the Accountable Health Communities (AHC) Model.
Although this 5-year initiative only began in 2017, one promising aspect of this model is the engagement of all the relevant service providers within a community (including health care services, public health, and social services) to achieve shared goals for a defined population.
The proposed AHC screening tool under current study includes 10 questions that screen for Housing Instability, Food Insecurity, Transportation Needs, Utility Needs, and Interpersonal Safety. Check it out here: https://nam.edu/wp-content/uploads/2017/05/Standardized-Screening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf
Screening program best practices
- The screening program should respond to a recognized need.
- The objectives of screening should be defined at the outset.
- There should be a defined target population.
- There should be scientific evidence of screening program effectiveness.
- The program should integrate education, testing, clinical services and program management.
- There should be quality assurance, with mechanisms to minimize potential risks of screening.
- The program should ensure informed choice, confidentiality and respect for autonomy.
- The program should promote equity and access to screening for the entire target population.
- Program evaluation should be planned from the outset.
- The overall benefits of screening should outweigh the harm.