This pilot was the first effort to develop and evaluate a standard workflow using questions embedded within the Epic EHR system to gather patient SDOH information within the Sutter Health network. We found evidence of positive reach, effectiveness, adoption, and implementation while also identifying challenges which will require further in-depth investigation to support quality implementation across Sutter. Eighty-three percent of eligible patients responded to the questionnaire and responsiveness by SDOH domain ranged from 55 to 67%, except for depression. Fifty-one percent of the patients had at least one identified social need, the most common being stress (33%), physical activities (22%), alcohol (12%), and social connections (6%). Average length of visit during the pilot was 39.8 min, which was 1.7 min longer than that during the same time in previous year. Most staff agreed that collecting SDOH data was relevant and accepted the SDOH questionnaire and workflow but highlighted opportunities for improvement in training and connecting patients to resources. Though few, we did observe differences in reach, effectiveness, and implementation across patient sociodemographic groups. There is a need to better understand those observed differences and actively work to prevent inequitable implementation as this intervention is scaled. The findings for each specific RE-AIM dimension assessed will be discussed in greater depth below.

Reach

We found no observable differences in sociodemographic characteristics between the participating patients in this pilot and the reference group of patients in 2019, indicating that the eligible patients in this pilot are likely similar to the patient population historically seen in the clinic. While 83% of the patients answered questions within at least one SDOH domain, only 3.5% of the patients completed all domains. Reasons for non-responsiveness may include discomfort with answering sensitive questions or the skipping of questions that patients did not feel were relevant to their lives. Much of current literature shows that patients perceive social risk screening as appropriate; however, research also emphasizes different factors which influence acceptability, such as trust in clinicians, clinical settings, and patients’ concern on privacy of social health data within their EHR [20, 38,39,40,41]. For example, a study by Cunningham & Sobell showed that adults feel that it is appropriate to be asked questions on alcohol use but may feel uncomfortable or underreport [42]. Stigma or shame was cited as barriers to disclosure of social needs like food insecurity [43]. The overall non-responsiveness to the depression domain questions (with only 7% of eligible patients responding) may also be indicative of stigma against mental illness, though evidence from other clinical sites suggests that depression screening is increasingly perceived as positive [44]. Further investigation is needed to understand why depression screening in the context of the overall SDOH questionnaire was unsuccessful. Additionally, our finding that females were more likely than males to respond to survey questions may be indicative of females’ greater recognition of the importance of screening. A study of patient perspectives on SDOH screening by Rogers and colleagues found that females were significantly more likely than males to agree that social needs screenings were necessary and should be a part of healthcare settings [45]. Overall, these findings emphasize the importance of patient-centered implementation of social risk screening. Due to the scope of this evaluation, we were not able to understand patients’ perspectives regarding answering the SDOH questionnaire. Future iterations of this intervention should incorporate a qualitative component to understand patients’ experiences of and feelings about answering the SDOH questions in the context of this standard workflow [45, 46].

Effectiveness

Half of the participating patients had at least one identified social need, with the most commonly identified social needs being stress, physical activities, alcohol, and social connections. These findings are similar to those reported in other studies that used different SDOH screening tools and workflows. A study by Page-Reeves and colleagues of patients in family medicine clinics also found identified 46% of patients having social needs [19]. A recent study by Tong and colleagues on a target population with a higher risk of having social needs reported a higher proportion (71–86%) of patients who screened positive for social needs, with the most common social needs included physical activities, dental, and alcohol use [23]. Despite the SDOH questions being available at Sutter Health in Epic since 2019, these questions were not used by physicians before the pilot. The fact that SDOH needs were identified in this pilot indicates the importance of having a standard workflow to gather SDOH information in a systematic way [15, 18]. Although we found certain differences in identified social needs across sociodemographic characteristics, small sample sizes limit the interpretability of these findings. Given the dearth of literature on whether identified social needs from screenings in clinical settings differ across patient populations, future research with a larger sample size and an incorporated qualitative component would provide the opportunity of examining potential disparities in the identification of social needs.

Overall, there was a strong support from staff in using the SDOH questionnaire and workflow to collect SDOH information as they were perceived to be important and effective in identifying social needs among patients. Although evidence was mixed, recent studies also show that social risk screening is perceived to be important by clinicians and healthcare team [23, 47, 48]. In this pilot, staff identified one possible challenge to effectively being able to collect SDOH information: that patients could feel uncomfortable answering the questions. Previous studies also reported concerns from clinicians related to ensuring that screening was done empathetically, without negative judgement, and with attention to privacy protections [19]. A qualitative study by Byhoff and colleagues found that patients actually felt more “cared for” or “listened to” when asked about social needs within a clinical setting, while emphasizing the need for “empathy” and “compassion” from staff conducting the screenings [46]. Accordingly, future implementations of this intervention must prioritize understanding patients’ experiences with answering the SDOH questions.

In the pilot’s standard workflow, physicians are a key gatekeeper of effectiveness, as they directly impact the translation of identified needs to action (whether within the exam space or through referral to case managers or social workers). Despite feeling that social needs information could help improve therapeutic relationship with patients, only one of the three responding physicians reported that having the information would influence their medical decision-making. Other studies found that knowing patients’ social needs not only improved patient-provider communications but also changed what clinicians do [23], such as providing more exercise and dietary counseling, being mindful of medication costs when prescribing, and helping with transportation to access to clinics. As only three physicians completed the staff survey, it was challenging to interpret physicians’ perceptions on changes of medical decisions without in-depth conversation, suggesting the utility of qualitative research with physicians in future pilots.

Adoption

The overwhelming majority of surveyed staff indicated that SDOH screening was relevant for their specific clinical population and within the scope of clinical care more generally. These findings align with the overarching recognition in health care delivery that understanding and engaging with patients’ SDOH needs should be incorporated into primary care settings [5, 15]. The majority of staff also felt the survey itself asked relevant questions and would be useful to support patients in connecting with resources to address social needs. In their study of 258 clinicians (physicians, social workers, nurses, and pharmacists) at Kaiser Permanente Southern California, Schickendanz et al., similarly found that the majority of those surveyed agreed that social need screening should be incorporated into clinical care and that knowing such information could be beneficial to patients [21]. These findings from our pilot site suggest the staff’s willingness to initiate SDOH screening. They also suggest that implementing plan-to-study-act (PDSA) cycles with a small group of staff before launching the pilot could be a potential strategy to engage staff in the pilot and their willingness to initiate SDOH screening. As the SDOH questionnaire and workflow is adapted and implemented at other Sutter Health sites, attention should be paid to any differences in adoption across locations so that factors which best facilitate adoption in the Sutter Health network can be identified.

Implementation

Because our study assesses a pilot program, we cannot speak to fidelity to the intervention with respect to the implementation of the SDOH questionnaire and workflow in other sites. Rather, our results speak to potential barriers that could hinder implementation at future sites – confusion regarding components of the standard workflow and the impact of the workflow on time [21, 22, 26]. While most staff felt they understood their role in the standard work, staff were less knowledgeable about and lacked training on available system resources to support patients and were also less confident in the ability to act on identified needs. Other studies have identified clinicians’ concerns that SDOH screening may not ultimately be helpful due to lack of availability or knowledge of, or access to, resources to address patients’ social needs as a potential barrier to implementation [23, 49]. The uncertainty expressed by staff speaks to the importance of incorporating information on this dimension of the workflow into staff trainings, including for staff who will not be directly supporting patients with next steps.

Time – specifically the additional time needed by patients and staff to complete the SDOH workflow – was a key concern for staff in the pilot. These concerns have also been identified in other studies of clinician perspectives [21, 26]. Our study did find that the average length of visits among eligible patients in 2020 was slightly longer than those in 2019, but the difference was not statistically significant. The longest added time period was the statistically significant difference of 5 min in exam time for Medicare wellness patients. One possible explanation for the exam-time difference for Medicare wellness patients is that Medicare wellness patients may have greater social needs, and so the results of the SDOH questionnaire may ultimately require more time with the physician to identify next steps. However, we did not observe that Medicare wellness patients had significantly more needs identified as compared with patients of other visit types. Medicare wellness patients may also have more complex health needs, and the evaluation for these patients may take more time due to Medicare requirements. Another possible explanation is the potential for particularly long visits to have a greater effect when comparing average values for a small number of visits (6% of our 2020 pilot population). Medicare wellness visits did have the most variability in lengths of the whole visit, rooming, and exam. Similarly, we observed small but significant differences in average visit lengths and lengths of specific sections of the visit across different sociodemographic groups (by age, insurance type, and visit type). However, without in-depth conversations with patients and providers, we cannot understand the impact these average length increases had on the experience of care, nor can we determine what may have been gained or lost by incorporated the SDOH workflow into the limited available time. In a qualitative study of social risk screening among patients and caregivers, participants expressed concern for the addition of the screening to already overworked clinician’s schedules [46]. In future iterations of the intervention, close attention should be paid to the quantitative and qualitative impact of the SDOH workflow on time so that adjustments may be made, whether to visit lengths or to the SDOH workflow, to minimize the time-pressure felt by clinic staff and patients and maximize the impact of the intervention.

Equity considerations

This pilot evaluation adds to the limited literature of SDOH assessments in clinical settings that examine whether there are disparities in screening and identification of social needs across different patient populations. Though observed in a small sample size, we identified some differences in reach, effectiveness, and implementation across patient sociodemographic groups. Understanding potential reasons for those differences could improve equitable implementation of SDOH assessment among patient groups. As addressing social needs is a strategy for reducing health inequities, SDOH assessment should be disseminated in clinical settings with a mindful approach that minimizes the potential disparities across patient sociodemographic groups.

Strengths and limitations

As the first study in the Sutter Health network to assess the incorporation of an SDOH questionnaire and workflow into a primary care setting, this evaluation not only provides feedback for further development of the intervention within the pilot clinic but also lays the groundwork for system-wide scale-up. Rather than assessing a single dimension of the intervention, this study synthesizes data from different sources to evaluate multiple elements of the intervention simultaneously. Through the use of the RE-AIM framework, this study presents a systematic approach to assessing social risk screening interventions that can be replicated by other clinics. Our study’s focus on identifying observable differences across sociodemographic groups also sets an important precedent for future studies to center considerations of equity throughout evaluations of SDOH screening interventions.

There are also important limitations of this pilot evaluation. Due to insufficient resources, we were unable to assess the effectiveness of the standard workflow in addressing identified patient social needs, a gap in the evaluation which must be prioritized in future intervention studies. A growing body of literature is examining the impact of screening for social risks in clinical settings on patient access to resources, healthcare experiences, and health, with evidence suggesting that such screenings are beneficial for patients [19, 49,50,51]. As we could not examine how patient’s social needs were addressed in this pilot, future pilots should prioritize assessment of referrals, receipt of social services, and overall impact on patients [28]. In addition, our study timeline was impacted by the onset of the COVID-19 pandemic, which in turn limited our sample size with respect to comparing metrics across sociodemographic groups. Relatedly, as the pilot only focused on a single clinic, small sample sizes precluded inferential statistics across staff groups. Also, as previously discussed, future studies should examine the reasons for non-responsiveness to SDOH questionnaires in order to suggest effective ways for collecting SDOH information. Finally, due to the COVID-19 pandemic, we were unable to complete the intended patient experience component of the evaluation. Gaining a deeper understanding of patient perspectives remains a priority for future implementation.

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