There is mounting evidence that screening for the barriers created by the social determinants of health (SDoH) has many positive benefits when addressing the needs of vulnerable populations. Diagnostic accuracy improves when physicians have a complete picture of a patient’s medical and social history. This same information also allows physicians to focus on the whole person instead of just treating the symptoms or disease. Studies have shown that when providers have the ability to address underlying issues it improves outcomes and controls costs by reducing emergency department usage and unnecessary hospitalization. This list could go on, but identifying all of the positive links between addressing social determinants and positive health outcomes raises the question of why aren’t more providers screening for the SDoH?
Specialty Specific Screening
While addressing this question, it is important to first point out that many providers are regularly screening for social determinants. As just one example, it has been more than two decades since obstetrics clinics began screening for risks that may prevent consistent prenatal care. These screenings generally include concerns such as safety, substance use, partner violence, food insecurity, and even frequent housing changes. There are also other specialties who regularly screen patients for food insecurity, abuse, or other types of violence.
Though screening is increasingly common, the concern is that most providers are only screening for a select few SDoH that are specific to their practices. In fact, a recent study of pediatric screenings revealed that over 60% only focused on a single risk factor and that fewer than 20% included five or more individual determinants. There is always value in identifying and addressing any potential barriers to patient success. However, when social determinant screenings are siloed by specialty it reduces their effectiveness by preventing providers from seeing the full picture.
Barriers to Comprehensive Screening
With risk specific screening common, the next logical question would be to ask why more providers aren’t attempting a comprehensive screening for the SDoH? There are probably many different answers to this question, but one industry literature review suggests that the lack of implemented screening programs starts with the concerns of physicians. Many providers feel like they lack the resources and skills needed to successfully start a screening program. They may also be hesitant to add yet another item to their ever-increasing list of responsibilities. There are also providers who are concerned that comprehensive screening will cause more harm than good if they lack the ability to actually address the identified needs.
Addressing the Concerns
Though not all physicians may be familiar with them, several resource programs do already exist to support screening for the SDoH. These include The National Association of Community Health Centers’ Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences tool, also known as PRAPARE. The American Academy of Family Physicians offers a social determinants of health screening tool as part of The EveryONE Project. The Centers for Medicare & Medicaid Services Accountable Health Communities has a tool that is meant to be self-administered and is known as Health-Related Social Needs Screening Tool or AHC-HRSN. Though these resources still need to be studied and understood by those administering them, they provide a necessary foundation for implementing a program.
Physicians being overburdened by screening responsibilities is another concern that is already being addressed. Until recently, the standard policy for medical coding was that only notes from clinical providers (i.e. physicians, physicians assistants, and nurse practitioners) could be included when using ICD-10 codes to update a patient’s records. This meant that the burden of screening was primarily falling on the physician since the observations and notes of any other members of the care team could not be included or tracked with coding.
At the encouragement of the American Hospital Association, these ICD-10 coding policies changed in February of 2018. According to the new policies, codes Z55 through Z56, which all deal directly with the SDoH, are no longer restricted to clinical providers. Applicable notes or observations from any member of the care team are now eligible to be included in the final coding. This change not only lessens the burden placed on the physicians, it increases the likelihood of screenings being completed because it allows for any designated member of the care team to complete the process.
Of course, removing the screening responsibility from the physicians is only part of the solution. It is also necessary to ensure that both the individuals completing the screening and the medical coders have the training and resources needed to effectively record the SDoH. The terminology used in ICD-10 codes and the terminology used in actual screening procedures do not always clearly match. This means that if a provider writes notes addressing social determinants, the medical coder may not understand how to accurately and consistently translate those notes into the proper codes. One relatively simple solution to this problem was demonstrated by The American Hospital Association when they released a document to explain the ICD-10 policy changes. Included in this document was a table that shows ICD-10 codes in one column and real world examples of what would be included in those codes in the other. This quick reference guide is an invaluable tool for ensuring accurate and consistent coding.
Healthcare providers are not equipped to address all of the needs that may be identified when screening for SDoH. However, the solution to this concern is not to avoid screening vulnerable populations, but to increase coordination with other providers. Community care coordination programs exist to allow health and human services providers to both identify needs and coordinate with the most appropriate resources to address those needs. As technology such as care coordination platforms, community information exchanges, and closed loop referral networks become more sophisticated, they provide the tools necessary to use comprehensive screening results to focus on whole-person care. And whole-person care is essential for providing vulnerable individuals access to all of the resources they need to succeed.