Understanding and Implementing SDOH Screening

What are social determinants of health?

Your health isn’t determined solely by how much kale you eat or how often you hit the gym (although those certainly help!). Sometimes your ZIP code, literacy level, or even your neighborhood grocery store (or lack thereof) can significantly influence your health outcomes. Let’s dive into how these unexpected factors, known as social determinants of health, shape a person's well-being.

Social determinants of health (SDOH) are conditions in the places people live, learn, work, and play that affect a wide range of health risks and outcomes. These factors include economic stability, access to quality education, healthcare availability, neighborhood safety, and social and community contexts. For example, lower-income neighborhoods often have limited access to nutritious food and safe spaces for physical activity, contributing to higher rates of obesity and chronic diseases.

Similarly, educational disparities affect health literacy, influencing individuals' abilities to understand health information and make informed health decisions. And let's face it, even the quality of food you eat and your access to fitness resources are both affected by how much you earn.

Identifying and addressing social determinants isn't just compassionate—it's smart healthcare. By recognizing these underlying factors, healthcare providers can deliver more holistic and effective care. But how exactly do we determine which social determinants are impacting an individual patient's health? That’s where SDOH screening steps in.

Identifying and addressing social determinants isn't just compassionate—it's smart healthcare.

What is SDOH screening?

SDOH screening involves systematically identifying social risk factors that impact a patient's overall health like food insecurity, housing instability, education barriers, and health insurance status. Think of it as a health risk assessment, but instead of focusing solely on clinical symptoms, it evaluates social and environmental factors that could hinder recovery or worsen health conditions.

You can typically use questionnaires for SDOH screening during patient visits to streamline data collection. This information goes into a patient's electronic health records. Screening can happen in settings outside of clinics and hospitals, from community health centers to medical research. It not only highlights hidden factors affecting patient health but also guides providers in connecting patients to appropriate community resources and support.

What is the importance of SDOH screening?

By recognizing the social conditions that influence individual health outcomes, providers can intervene earlier and more effectively. For instance, knowing a patient struggles with food insecurity can prompt referrals to local food banks or nutritional programs, directly improving their health.

Without SDOH screening, underlying issues often remain invisible, leaving patients struggling unnecessarily.

SDOH screening also helps family physicians and other providers create personalized treatment plans, potentially reducing emergency room visits and healthcare costs. Without SDOH screening, underlying issues often remain invisible, leaving patients struggling unnecessarily.

SDOH screening tools

There are several screening tools you can use in various settings. Here's a quick list:

1. The National Association of Community Health Centers’ PRAPARE tool: Administered in community health centers, typically integrated into electronic health records.
2. American Academy of Family Physicians’ Social Needs Screening Tool: Available in both long and short forms, suitable for primary care settings.
3. Centers for Medicare & Medicaid Services’ Accountable Health Communities Health-Related Social Needs Screening (AHC-HRSN) Tool: A concise, 10-question tool often used in large community-based health programs to systematically assess health-related social needs.
4. WE CARE: Designed specifically for pediatric practices, integrated into regular patient check-ups.
5. HealthBegins: Commonly utilized in clinical and community-based organizations, emphasizing actionable referrals.
6. Health Leads: Often administered by healthcare staff or volunteers to directly connect patients with community resources.
7. WellRX: Suitable for diverse clinical settings, including family practices and hospitals, easy to incorporate into routine screenings.
8. HelpStep: Usually employed in outpatient and emergency department settings to quickly identify social issues and make rapid referrals.

Implementing SDOH screening

Integrating SDOH screening into your practice involves clear planning and teamwork. Begin by selecting an appropriate screening tool tailored to your patient demographic and clinical setting. Train your staff thoroughly on how to administer the screening sensitively, ensuring they understand its importance and how it benefits patients.

Next, utilize electronic health records for smooth data collection and tracking outcomes. Establish strong partnerships with local community resources and social services to facilitate rapid referrals. Regularly review and update your screening processes to address any emerging challenges or gaps, continually refining your approach for maximum effectiveness.

Examples of how SDOH screening makes a difference

Okay, let's talk about situations where an SDOH screening would spell the difference between poor patient care and holistic care.

Case 1: Addressing food insecurity

A patient with diabetes consistently showed up for appointments with dangerously uncontrolled blood sugar levels. Without an SDOH screening, their doctor might have assumed they were simply ignoring advice, being forgetful, or neglecting their medication.

However, a routine screening revealed the patient faced severe food insecurity, making adherence to dietary recommendations nearly impossible. The healthcare team connected the patient with local community resources, including a food pantry and nutritional counseling, which dramatically improved their health outcomes.

Case 2: Bridging transportation barriers

Another patient, elderly and living with chronic heart failure, frequently missed crucial medical appointments. Without deeper insight, healthcare providers could easily interpret these absences as signs of apathy or forgetfulness.

An SDOH screening instead uncovered a lack of reliable transportation. The patient was promptly connected to transportation services provided by a community-based non-profit, significantly improving attendance and overall disease management.

Remember the infamous Dr. House from the TV show House MD? His mantra is "Everybody lies," and he and his colleagues would delve deeply into their patients' lives—often crossing ethical lines and invading patients' privacies in pursuit of hidden truths. While House’s methods would land real doctors in serious trouble, his reasoning holds merit: understanding a patient fully requires looking beyond surface-level symptoms.

In reality, systematic SDOH screening provides a practical, ethical alternative, helping healthcare professionals understand and address hidden barriers to health.

Key takeaways

• Social determinants significantly influence individual health outcomes beyond traditional medical factors.
• SDOH screening tools identify social risk factors such as food insecurity, housing stability, and transportation barriers.
• Implementing routine SDOH screening connects patients to vital community resources, improving overall health outcomes.
• Effective SDOH screening enhances patient care, reduces healthcare costs, and promotes holistic treatment approaches by addressing underlying social factors.