During a routine medical appointment, you might expect to field questions about the diseases that run in your family and the medications you take. But the next time you’re sitting in an exam room, don’t be surprised if a doctor, nurse practitioner or physician’s assistant brings up topics they haven’t broached before, like where you buy food and how you get around your neighborhood. They’re probably performing what’s known as a social screening.
Our understanding of health, and how it’s influenced by our day-to-day lives, is constantly evolving. Research suggests that behavioral and economic factors account for more than 80 percent of health outcomes. More healthcare providers are taking findings like this to heart and building questions about social determinants of health, i.e., the environments in which we live, play and work, into primary care visits.
“Inadequacies in meeting basic needs such as food, housing, transportation and other conditions have the potential to create environmental stress and can have a profound effect on health,” says Teri A. Murray, professor and dean emerita of the Valentine School of Nursing at Saint Louis University.
Right now, one-quarter of physician practices and 16 percent of hospitals screen for food insecurity, housing instability, utility needs, transportation needs and interpersonal violence, according to a new study by Beidler and her colleagues. They surveyed 2,190 physician practices and 739 hospitals to get a baseline for how common these screenings are. Additionally, practices serving disadvantaged patients reported higher screening rates. However, one-third of physician practices and 8 percent of hospitals do not screen for any social determinants of health.
“I don’t think these numbers say there is a failing by healthcare,” says Laura Beidler, research project coordinator at the Dartmouth Institute for Health Policy and Clinical Practice. “This is really hard and really new. Healthcare providers haven’t been trained to do this and we’re figuring it out as we go.”
She predicts that the number of doctors and hospitals screening for these things will only increase. And that benefits all of us.
Here’s why social screenings might be unfamiliar
While social screening programs are valuable, getting more hospitals and doctor’s offices to implement them won’t be easy. “It’s a change for medicine,” Beidler says. “New systematic screenings require time, training staff, sometimes hiring more staff, and building the screening into the electronic health record.”
Some providers are also hesitant to broach potentially sensitive topics, worrying they’ll seem offensive or intrusive, according to the American Hospital Association. “They also feel that if they know the patient has a need, it’s their responsibility to address it, and some may not feel prepared to address it,” Beidler adds. In a 2011 survey of 1,000 physicians, 85 percent said social needs are as important to address as medical conditions, but only 11 percent “strongly agreed” that they were well-informed about resources they could use to help patients manage their unmet social needs.
Additionally, unlike hospitals, most doctor’s offices lack an incentive to implement social screenings. In Beidler’s study, hospitals that were part of accountable Care Organizations, or ACOs, were more likely to screen. ACO providers work in teams in an effort to reduce errors and make care more efficient and inexpensive. If they can prove they’re keeping patients healthier and addressing social needs, they might receive a bonus from the payer, meaning Medicare, Medicaid or a private insurance company. So, performing social screenings might literally pay off for ACOs. That’s not the case for other types of healthcare practices. Not to mention, safe discharge laws also require most hospitals to make sure a patient has access to everything they need in order to follow their care plan when they’re back home, including utilities, transit and food.
That said, time-crunched doctors probably wouldn’t administer these screenings themselves, which should make them more feasible to implement. “My guess is that in most organizations doing this, the providers are not the ones who have to ask,” Beidler says. “I think it happens at intake or the medical assistant asks when they room the patient.”
Whether or not patients have unmet social needs, talking about your day-to-day life might ultimately improve doctor-patient relationships. “Taking a couple minutes to answer these questions may foster a greater appreciation for the lengths to which a care team wants to understand people as people, serve them and find thoughtful solutions for their needs,” Berkowitz says.
There’s also an economic reason to support social screenings. The U.S. already spends much more than any other country on healthcare, and costs are projected to keep rising steadily for the next few years. Screening might be one way to reduce spending: One AmeriHealth Caritas analysis found that screening for and addressing social health determinants decreases inpatient admissions by 26 percent, and reduces both the volume of ER visits and the length of hospital stays for high-risk Medicaid members. “Much of healthcare costs and outcomes are driven by unmet social needs,” Beidler explains. “Screening is the first step to helping patients address those needs, which could lead to better health outcomes, such as better management of chronic diseases and better nutritional status, and lower costs, such as fewer hospitalizations and fewer ED visits.”
It takes a community
Routine wellness exams and vaccination play a vital role in keeping us healthy, but clinical care accounts for only 16 percent of our overall health outcomes. As a result, hospitals and other organizations — including the American Academy of Family Physicians, Office of Disease Prevention and Health Promotion, and National Association of Community Health Centers — are encouraging training for doctors to identify and address social determinants of health. Healthcare providers can then tailor treatment plans and connect patients with community resources.
For someone diagnosed with diabetes, for example, it’s important to have access to food that can help them manage their condition. But if they live in a food desert where no store sells fresh produce and they don’t have a car or the physical stamina to take public transit to another neighborhood, following a care plan can become prohibitively difficult. If a doctor is aware of these barriers, they can take measures to help the patient address them. That could mean working with a local food pantry that delivers groceries or setting up a Meals on Wheels service.
Community services like these are key, says Scott Berkowitz, senior medical director of accountable care at the Office of Johns Hopkins Physicians at Johns Hopkins Medicine. “To have the maximal chance to improve care for patients, we have to have good community partners.”
Different hospitals across the country have implemented such programs: Some have developed affordable housing for those in need, while others work with Uber and Lyft to provide transportation even if a patient doesn’t have the apps. The CalvertHealth Medical Center in Maryland has a mobile health center that brings healthcare services to patients who cannot travel, and the Preventive Food Pantry at Boston Medical Center provides low-income patients with special nutritional needs with healthy foods, including fruits and vegetables.
“Nurses and social workers can also advocate and work with the local municipality on zoning laws, how much green space a neighborhood has, and other things that keep the community at an undesirable level and could negatively impact health,” Murray adds.
So, if a doctor or any other healthcare provider asks you how far you live from a grocery store, or whether you rely on public transportation to get around, just be honest. That way, you can work together to create a treatment plan that you can actually follow, thereby making it easier for you to stay on top of any health issues — and hopefully spend less time seeing doctors.
“I’m a cardiologist,” Berkowitz says. “If I understand that a patient is not going to be able to get to a certain site for treatment because of a transit difficulty, or that they may not be able to get a medicine because of a financial barrier, or that they may not show for follow-up visits because of a domestic problem, that influences the way in which I try to approach their care. I want to make sure they can receive the types of services they need.”
Working with community health workers or social workers, you may discover local organizations that you never knew existed that can help support you with transportation, food and other needs. Healthcare is no longer just a physician treating a disease. Increasingly, it’s becoming a team of people working together to improve patient well-being.