Making the Social Determinants of Health a Routine Part of Medical Care
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Background
The impact of social and economic factors on health and disease has been well documented.1,2 Broadly defined, socioeconomic determinants are the conditions in which people live: where they are born, grow up, work, and age. These conditions affect a person’s health and vulnerability to disease, and very often vary by wealth, social status and gender. While all health practitioners have the potential to address socioeconomic status as a contributor to suboptimal health status, providers working in underserved communities are keenly familiar with the imperative to address the social determinants of health for their patients.
Though the ethical and clinical imperatives to address these issues is appreciated by many, screening for conditions takes time, and the reality of limited time often competes with the urgency of a clinic visit or other evidence-based interventions delivered by the health care team at the time of an encounter. Therefore, screening for socioeconomic determinants of health, like many other routine clinical care tasks, must be as brief and evidence-based as possible, and shared by all members of the health care team.3 The use of technology via clinical decision support systems (CDSS) to help the team remember to perform routine tasks has been shown to improve screening for many conditions,4 and their use can also assist with screening for socioeconomic determinants of health. Finally, as is the case for any condition that is screened, a bona fide intervention should be available to address a positive screen. Using these overarching principles of thorough and efficient team-based care, a comprehensive system to screen for several socioeconomic determinants was implemented for an entire health center population.
This ACU Column focuses on Norwalk Community Health Center’s (NCHC’s) adoption of diagnostic screening tools to detect relevant information in the fields of housing, intimate partner violence, alcohol misuse, illicit substance misuse, tobacco use, sexual activity, and mental health/depression. By screening every patient with evidence-based, validated screening tools, NCHC reaffirms the importance of detecting social factors that determine risk for illnesses and can have profound influence on treatment. [End Page 321]
Potential Barrier to Screening: Time
As in many office-based settings, a typical patient visit at NCHC can sometimes feel disjointed and hurried, as much has to be accomplished within a short time. Our solution was to find evidence-based screening tools (with a preference for tools validated in a multi-lingual, underserved setting) that could be administered by a medical assistant when a patient initially engages in an office visit. Positive responses would then lead to appropriate physician-directed intervention, significantly decreasing the burden on providers to perform screening. The barrier of limited time was further addressed by a change in workflow, based on team care principles.5 Significant changes in the electronic medical record (EMR) template design allowed screening roles to be better defined, whereby screening tools were put into the medical assistant section of the form (Figure 1). This clear demarcation within the EMR was critical in ensuring a complete and streamlined office visit that checked on relevant socioeconomic characteristics.
Screening Tools
The screening tools used are all evidence-based, most of them validated in underserved settings and in multiple languages. The choice of tools reflected the need to maximize efficiency, sensitivity, and specificity. The tools used for most of the screenings are described below.
Housing
The housing screen was the one for which we could not locate a validated methodology. We worked with staff and our Medical-Legal Partnership (MLP) attorney partners, who have experience in advocating for clients with substandard housing, to create a screening tool that was brief and likely more sensitive than specific. This screening tool is made up of two components—an initial yes-or-no question (“Is your health or families’ health affected by conditions at home?”), followed by a checklist (“Check all conditions that exist in the patient’s home: bug infestation, mold, lead paint/pipes, inadequate heat, non-functioning oven/store, no or non-working smoke detectors, water leaks”) (Figure 1...
