Kailin Lieu, MD- Senior Director, Ambulatory and Clinical Programs
Social determinants of health (SDOH) are increasingly becoming recognized as a crucial part of overall health. The concept that health is all clinical has become outdated, in favor of a more multifactorial representation of the reality that health is only 20% clinical care and 80% non-clinical. For the non-clinical aspect, 30% is attributed to health behaviors, 10% to physical environment, and 40% to socioeconomic factors.1
Unaddressed SDOH needs can have serious clinical and emotional ramifications. Children who experience food insecurity are at a higher risk of developing negative health outcomes, such as cardiovascular disease, obesity, type 2 diabetes, certain types of cancer, and developmental problems.2 Those who do not have stable housing are more likely to develop asthma, lung cancer, chronic stress and anxiety, and depression; they may also experience injuries and illness related to dangers, such as lead poisoning, carbon monoxide exposure, and fires.3,4
Given the significant effects that SDOH needs can have on health, the Centers for Medicare & Medicaid Services (CMS) implemented two new mandatory inpatient quality reporting measures related to SDOH for patients age 18 and older at the beginning of this year. They are requiring hospitals to screen the adult population for SDOH needs related to food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety, and to report the positive rate for these needs.5 In response to this new mandate and client requests to facilitate and augment their SDOH initiatives, Get Well has developed a tech-enabled SDOH solution that addresses the following aspects: screening, EHR integration, resource navigation, and closing the loop.
Even though these mandates only apply to the adult population, as trends have shown, it may only be a matter of time before they are extended to the pediatric population. Recognizing that SDOH plays a critical role in children’s development and health, many pediatric health systems have already implemented SDOH initiatives, which was the focus of our most recent Pediatric Leadership Cohort session. Get Well hosts these quarterly sessions to bring together pediatric leaders across the country to share challenges and best practices. In our pre-session survey, most clinical leaders indicated that their healthcare systems were doing well with screening, EHR integration and, to some extent, resource navigation; however, closing the loop was something that the majority struggled with. Clinical leaders from a number of pediatric healthcare organizations attended our session and discussed their SDOH programs and the unique challenges of addressing SDOH needs in pediatrics. The following highlight top insights from pediatric leaders, along with Get Well’s solution to each of these SDOH domains:
Screening: identifying SDOH needs
- SDOH questionnaires are typically administered on paper or digitally, either by a staff member or self-directed by the patient or caregiver. The mode of administration largely depends on healthcare system workflows and patient preference, though consideration should be given to how comfortable staff members are asking sensitive questions and how comfortable patients or caregivers are being asked such questions. Role play during training has helped staff members feel more comfortable screening patients and caregivers for SDOH needs.
- Underscoring the value of SDOH screening through education and data transparency is key in securing buy-in from staff members who are being asked to take on more responsibilities with this process.
- Pediatric healthcare organizations have different criteria for when to start screening patients instead of caregivers and what to screen for based on state regulations.
Get Well has a digital SDOH survey that can be configured at the healthcare-system level and texted out to patients to screen for SDOH needs.
EHR integration: auto-populating SDOH needs and resources shared into the EHR
- Most healthcare systems either manually- or auto-populate SDOH needs into the EHR. The way this information is displayed is variable, with some choosing to present it on the main page and others choosing to present it under a certain tab or as part of a specific report.
- Care team members may need additional training to incorporate SDOH review into their workflow before seeing patients, especially if SDOH information is filed under a certain tab or report instead of displayed on the main page.
Get Well is able to capture patient responses to SDOH screening by ingesting responses already stored in your systems from current investments and administering screenings where needed to facilitate reporting, tracking, and care coordination.
Resource navigation: navigating patients to requested resources
- Community health workers are integral in connecting with patients and navigating them to resources, especially when healthcare organizations are short-staffed and overwhelmed.
- Resources can be shared with patients and caregivers in a number of ways, such as via text message, email, mail, phone, or as paper collateral given at the clinical encounter. It is best to offer patients and caregivers the choice of how they wish to be contacted to accommodate their preferences.
- Partnerships with social care platforms, such as FindHelp and UniteUs, can be beneficial in expanding the resource base.
Get Well’s platform seamlessly integrates with various community based organizations (CBOs) to connect patients with personalized social care resources. We provide both automated resourcing that is personalized to patients and additional requested resources that navigators can surface and send.
Closing the loop: following up on the effectiveness of resources
- One of the main challenges is maintaining patient engagement and follow-up after discharge, as well as having dedicated resources to close the loop with patients after they leave the inpatient or ambulatory setting.
- Funding is another barrier, with many healthcare organizations pursuing grants when budgets do not allow for resource follow-up activities.
Get Well’s flexible API strategy enables integrations with CBO aggregators to receive status updates on referrals made in the patient’s community. These statuses can be used to engage patients on shared resources or find alternatives to ensure their needs are being addressed.
Please reach out for more information if you are interested in learning more about Get Well’s SDOH solution. If you are a pediatric care leader and would like to join our Pediatric Leadership Cohort, register here.
References:
- Explore health topics. County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/what-impacts-health/county-health-rankings-model
- Cook, J.T. (2013, April). Impacts of child food insecurity and hunger on health and development in children: Implications of measurement approach. In Paper commissioned for the Workshop on Research Gaps and Opportunities on the Causes and Consequences of Child Hunger.
- Gove, W.R., Hughes, M., Galle, O.R. (1979). Overcrowding in the home: An empirical investigation of its possible pathological consequences. American Sociological Review, 44(1), 59–80. DOI: 10.2307/2094818
- Hernández, D. (2016). Affording housing at the expense of health: Exploring the housing and neighborhood strategies of poor families. Journal of Family Issues, 37(7), 921–946. DOI: 10.1177/0192513X14530970
- Gallegos, A. (2024). New SDOH reporting requirements expected to impact HI workflow, staffing. Journal of AHIMA. Retrieved from https://journal.ahima.org/page/new-sdoh-reporting-requirements-expected-to-impact-hi-workflow-staffing
