Social Determinants of Health Screening Implementation: A Multi-Method Investigation to Bridge Clinic and Community to Improve Healthcare Outcomes

Abstract

Motivated by transitions to value-based payment programs, healthcare organizations are beginning to implement social risk screening and referral programs to address patients’ social needs. This dissertation explores current efforts to conduct social risk screening in healthcare settings to identify social needs, as well as the policy and organizational factors associated with healthcare organizations’ social care services to address those social needs.

In Aim 1, qualitative interviews are used to explore providers’ experiences with social risk screening, including perspectives on the benefits and drawbacks of the use of social risk data, as well as how they data are used in practice. This study draws on professions theory as a framework to characterize the impact of the introduction of screening and referral work on clinicians, for whom this work may fall outside of their professional jurisdiction. This study describes the need to support clinicians as they perform screening and social care tasks via education, designated staffing, and informational tools. The adoption of social care work by clinicians represents a unique contribution for professions theory by demonstrating a case in which professionals expand their scope of practice involuntarily due to the managerialization of social needs.

In Aim 2, qualitative interviews are used to understand the patient perspective of social risk screening, including attitudes towards the disclosure and documentation of social risk data, as well as expectations for providers’ response to disclosed social needs. Using medicalization theory as a framework, this study explores the impact of the healthcare efforts to exert social control on patients through screening and social care programs. This study identifies facilitators of sharing information about social needs, including believing that data are relevant to accessing healthcare, having an expectation that providers can address social needs, and having trusting relationships with providers. Barriers to sharing information about social needs during screening are also identified, including feeling that social risk data are irrelevant to providers and perceiving risks of screening, including embarrassment, discrimination, or bias. This study highlights the potential harms of social control that may follow screening, suggesting the need for patient-centered design of screening and social care programs.

In Aim 3, national survey data from US hospitals is combined with Community Benefit spending data to characterize those hospital characteristics associated with providing social care services. This study demonstrates that increased Community Benefit spending is positively associated with the number of social care services offered by a hospital. However, hospitals in states with minimum Community Benefit spending requirements were negatively associated with the number of social care services offered, suggesting opportunities for new policy incentives to encourage the implementation of additional capacities to address patients’ social needs.

Together, these Aims intend to guide the implementation of future social risk screening programs to ensure feasibility for providers and their workflows as well as acceptability for patients. The medicalization of social needs may create additional opportunities to address patients’ social needs, though screening and referral programs may shift provider work practices and change patient-provider relationships, suggesting the need for consideration of these factors during the design and implementation of programs. As hospitals take responsibility for social needs, they must have sufficient capacity to promptly offer resources. The findings of this dissertation may help improve screening and social care programs implementation to create opportunities to address patients’ needs and improve healthcare access.