Universal screening for social determinants of health (SDOH) and heath related social needs (HRSN) is undeniably an important tool for health equity. Reaching out to people who are rarely seen, or who tend to be quiet about their non-medical issues and giving them an opportunity to explicitly express their needs can open doors that would otherwise stay shut. Over the past decade I’ve personally spearheaded multiple efforts to implement such screening programs and to act on the information provided.
Completely aside from screening, however, many patients are already speaking up about these issues, especially in the context of what is affecting their health the most. Patients regularly tell their medical and behavioral health teams all about the stresses in their lives. Appointments are missed because of transportation and childcare issues. Coughs are explained as starting since the mold appeared on the walls. Depression and anxiety are often tied to job insecurity. Despite these stories being told and recorded, this type of information rarely becomes “structured data.” Instead, it languishes in the clinical notes, and only the most dogged clinicians have the tenacity or the time to try and address these social issues, even when there is a team member down the hall ready to assist.
On the other hand, major investment is going into formal screening programs, driven by processes such as CMS’s Accountable Health Communities and the soon-to-launch NY Medicaid waiver. These funded screening efforts (unlike the current CMS screening quality measures) also provide explicit resources to build extended teams with care navigators, community health workers and social workers to help the screened patients connect with and (hopefully) receive the non-medical services needed to allow them to better focus on their health.
Other payment changes enable addressing SDOH/HRSN without requiring specific screenings to be conducted. For example, the newly funded Medicare Community Health Integration codes pay for navigation services regardless of the means of recognizing the source of the patient’s need. Under California’s Medicaid waiver program, CalAIM, medically tied services such as housing deposits, medically supportive food, and home modifications for accessibility and asthma remediation can be provided based on clinician “order” under the community supports (CS) part of the program. Persons recognized as having even higher social risk factors, such as those experiencing homelessness, caring for foster children, and those leaving incarceration are able to access these benefits under enhanced care management (eCM). Each of these mechanisms presents an immediate opportunity to use the information already being provided by the patient as part of the “History of Present Illness” or other components of the discussions between the patient and clinician or team members.
Key to all these efforts are the standards around SDOH/HRSN being generated by the Gravity Project for the purpose of categorizing social needs in a way that can be universally understood and shared across data systems. The Gravity Project encoded social needs domains and their attendant ICD, SNOMED and LOINC codes are mapped to screening tools, however, the codes can be assigned to a patient on the basis of a wide variety of information gathering processes, including interviews with clinically supervised health paraprofessionals. It is uniquely recognized by CMS that assigning these codes does not have to be added to the clinicians’ day to day burden. That said, the clinician record can and should be an important source of information about social needs.
[Of note, when I systematically queried the makers of ambient clinical note writing software at HIMSS 2024 about inclusion of this social information in the notes generated by their AI, with one exception, they said it would definitely or most likely be discarded by the AI note writing process. Clearly this is fodder for another blog…]
Again, screening is an important means to hear from those who are not speaking up, but for patients who are already saying loud and clear what is getting in the way of their wellbeing, let’s respect the trust they have put in us. We can act now as a team to address these barriers to thriving, not wait for a validated screening tool to unlock our attention or services. My next blog will address how Augintel’s existing natural language processing can do just this today.
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