Whether it's regarding a follow-up appointment or exercise and diet recommendations, hospitalists give a lot of instructions to patients leaving the hospital. It's less common that hospital staff consider whether patients have the resources to follow their advice.
“We tend to assume that the patient's going to be able to meet our expectations for physical activity or whatever the prescription might be,” said Gregory Kane, MD, MACP, professor and chair of the department of medicine at Jefferson Health in Philadelphia. “Changes in diet, exercise or activity, or other specific types of follow-up . . . may not be easy for the patient to accomplish, depending upon where they live and their own personal social determinants of health.”
Social determinants of health (SDOH) have become an increasing focus for hospitals and clinicians, thanks to research showing that addressing a constellation of social, economic, and environmental factors can improve health outcomes and reduce costs. A study published in Population Health Management in November 2018 found that meeting patients' social needs reduced the cost of care by $2,400 per patient.
CMS, ACP, and other organizations have recently encouraged physicians and health care organizations to look at SDOH among their patients. Questions remain, though, about how this broader focus translates to hospital care and whether hospitals, and hospitalists, should be tackling patients' social as well as medical ills.
The push to screen
Last April, the director of the CMS Office of Minority Health published a blog post urging clinicians to screen for five SDOH in their patients: housing instability, food insecurity, transportation needs, utility needs, and interpersonal violence in the home.
The post included links to screening tools, such as CMS's Accountable Health-Related Social Needs Screening Tool, and a table of ICD-10-CM Z codes that can be used to capture patients' socioeconomic and psychosocial needs. CMS is also testing the Accountable Health Communities Model, which is examining whether systematically addressing SDOHs in Medicare and Medicaid beneficiaries affects costs and health care utilization. The pilot began in May 2017 and is expected to conclude in 2022.
In April 2018, ACP published a policy paper, on which Dr. Kane was a coauthor, that called for increased efforts to understand the role of SDOH in individual and community health and to implement public policies that reach a large number of people but also address day-to-day needs. “Awareness of social determinants of health may not always translate into better health outcomes, but it is an important component of the physician's role as an advocate for patients and a steward of medical care,” the paper said.
Screening for SDOH appears to vary at the hospital level. A recent study found that only about a quarter of U.S. hospitals routinely ask patients about the five SDOHs outlined by CMS. “Given the current focus on social needs from state and federal policymakers, payers, and physicians and hospitals, it seems likely that pressure on physicians and hospitals to identify and begin addressing patients' social needs will continue,” the study authors concluded in the September 2019 JAMA Network Open. “Physicians and hospitals may need additional resources to screen for or address patients' social needs.”
In addition, a 2017 survey of U.S. hospitals conducted by Deloitte found that while 88% reported screening for social needs, 26% of this screening tended to be ad hoc rather than systematic, and 40% of hospitals that screened had no current capability to measure the outcomes of their activities, according to David Rabinowitz, a senior manager at Deloitte.
Given the newness of these efforts, there's still some uncertainty about the best way to conduct inpatient screening. “There are multiple possibilities,” Dr. Kane said. “It could be [medical assistant] staff in the ER setting, it could be nursing staff on the floor, it could be social work staff, or it could be treating physicians, including resident and attending physicians, who could acquire or screen some of these key issues.”
According to ACP Member Iman Hassan, MD, MS, director for community and population health initiatives and an assistant professor at Montefiore Medical Center in the Bronx, hospitalists are well positioned to lead screening efforts by modeling effective communication for staff and helping patients make the link between their living situations and their overall health.
“By requiring more complete social histories on admission, explicitly asking about social needs, and encouraging team members to present unmet social needs impacting health as separate issues, we can be more successful in helping our patients overcome barriers to health,” she said.
Whoever does the screening, it's important for clinicians to get the specifics of patients' responses. “Not every issue applies to every patient,” Dr. Kane said. “Some patients . . . don't live near a good source of [fresh] food, and they have some budgetary limitations, but they could certainly walk and exercise. In other areas the patient has the means for maintaining their diet and good family support, but they don't have a safe neighborhood for walking.”
These issues should not be conflated with socioeconomic status, said Mr. Rabinowitz. “Sometimes people think that social determinants of health only affect low-income populations or that it is only impactful for a specific population, but in reality, [they] impact all people,” he said. “For instance, an elderly person may not be able to drive to get to an appointment. Understanding their living situation can help better anticipate ways to improve their care.”
Issues with screening
However, not everyone agrees that adding this kind of screening to hospitalists' task lists is the best way to improve inpatient care. Hilary Mosher, MFA, MD, a hospitalist and director of the general internal medicine fellowship program at the University of Iowa Carver College of Medicine in Iowa City, believes SDOH-specific screening in the hospital is unnecessary, since hospitalists already rely on motivational interviewing and other patient-centered care techniques to gather social risk information while taking a history and making recommendations.
“At the patient-facing level, screening for health risks like domestic violence is nothing different than what we've already been teaching about patient-centered care,” she said. “The medical team's job, broadly defined, is already to engage in collecting this kind of information as it directly affects the patient that is in front of them.”
In the JAMA Network Open study, the most commonly cited barriers to implementing a SDOH screening system included lack of time and resources and fear of moral injury to the physician and other clinicians.
“For health care teams constantly coming up against issues that are beyond the scope of their practice, like transportation or poverty, then there comes with that an accumulated sense of frustration and helplessness from trying to solve problems that are not within their immediate self-efficacy,” Dr. Mosher said. She also noted that there are risks to patients from broad SDOH screening if there is no plan in place to act on the resulting information.
Dr. Kane acknowledged this challenge. “We can't necessarily solve all of the social determinants of health that present to us. Certainly you can't necessarily alter your patient's financial situation. But I think by being aware, it allows a hospitalist to partner with their patient to put together the best plan upon discharge,” he said.
It's ideal when SDOH screening can be part of larger public health or social initiatives, according to Michael Silverstein, MD, a professor of pediatrics at Boston University and associate chief medical officer for research and population health at Boston Medical Center. “Health systems and people that work in them are just one aspect of a broader network of social support and societal organizations that can help,” he said.
For some types of SDOH, hospitals are an effective place to screen and potentially treat, but for others they are not, he said, offering the example of lead levels in children. “Once you identify a child with an elevated blood lead level, there's really not much you can do about it. A better approach would be to, for example, screen water supplies, or screen houses, and go more proximal to the source of the problem,” Dr. Silverstein said.
He was the lead author on a viewpoint published by JAMA on Dec. 2, 2019, calling for a balance between clinical care and public health in addressing SDOH. “Simply importing public health concepts into clinical care as stand-alone programs, and changing intervention targets from populations to individuals, reduces the intentionally broad population health model. More importantly, force-fitting strategies to address social determinants of health into traditional models of clinical care risks misdirecting limited resources into programs that may ultimately prove inefficient or ineffective,” he and his coauthors wrote.
To avoid these perils, hospital leaders should clarify their ability to respond to the SDOH they might find before implementing screening, the experts said.
“It is important to screen for social needs that can be addressed with existing health system, community, and government resources,” Dr. Hassan said. “It is also imperative to ensure that resources for addressing needs are in place before commencing universal screening for a particular social need. At Montefiore, we have selected a few social needs categories to screen for that have been shown to directly impact health outcomes and for which clinic and community resources are available.”
For example, she said, Montefiore has screened over 1,000 hospital patients for SDOH and has worked to provide temporary postdischarge housing when needed for its highest ED utilizers.
Information on SDOH, whether derived from screening or from the patient-physician encounter as part of patient-centered care, could potentially be used by discharge coordinators, social workers, care navigators, nurses, and others on care teams to help identify additional services and resources in the community, Dr. Mosher noted. She also stressed that it's important for the results of SDOH screening to be actionable.
“Are there questions that we should be asking that we're not, and are we collecting data in a way that our analysts can use that would help create community-based solutions like food Rx programs in food deserts or transportation where there isn't any?” she asked. “I think there is a role for hospitalists to act on their findings in terms of doing patient-centered care,” but it should be up to the hospital administration to “make intelligent decisions about how to more efficiently provide health care to their populations,” she said.
Such big-picture goals have motivated ACP and other entities' current focus on SDOH, according to Dr. Kane. “I view it as part of the natural maturation of American medicine. I think we are really focusing today on what high-quality care means . . . a partnership between the treating physician and the patient to try to maximize their health and address those factors that really are key,” he said.