Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system

Abstract

Introduction: Health systems have many incentives to screen patients for health-related social needs (HRSNs) due to growing evidence that social determinants of health impact outcomes and a new regulatory context that requires health equity measures. This study describes the experience of one large urban health system in scaling HRSN screening by implementing improvement strategies over five years, from 2018 to 2023. Methods: In 2018, the health system adapted a 10-item HRSN screening tool from a widely used, validated instrument. Implementation strategies aimed to foster screening were retrospectively reviewed and categorized according to the Expert Recommendations for Implementing Change (ERIC) study. Statistical process control methods were utilized to determine whether implementation strategies contributed to improvements in HRSN screening activities. Results: There were 280,757 HRSN screens administered across 311 clinical teams in the health system between April 2018 and March 2023. Implementation strategies linked to increased screening included integrating screening within an online patient portal (ERIC strategy: involve patients/ consumers and family members), expansion to discrete clinical teams (ERIC strategy: change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical data to providers), and deploying Community Health Workers to address HRSNs (ERIC strategy: create new clinical teams). Conclusion: Implementation strategies designed to promote efficiency, foster universal screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening demonstrate the cumulative effects of implementation strategies and the health system's commitment toward universal screening.

Understanding individual health-related social needs in the context of area-level social determinants of health: The case for granularity

“…As HRSN screening becomes the standard of care across health systems, aligning the timeframes of these measures and analyzing them longitudinally may become easier and prove a fruitful avenue of investigation. Screening for HRSNs has also been implemented in a pragmatic fashion within this clinical setting [ 38 ], which has the potential to introduce a sampling bias for those patients screened for HRSNs. However, the demographics of those patients screened for HRSN match those of the health system as a whole, increasing our confidence in the representativeness of the sample (supplemental table ).…”

“…While not every patient in the health system was screened for HRSN within the study period, each clinical team was given the discretion to decide which patients to screen (i.e. new patients, patients seen for annual physicals, patients with high-risk comorbidities) [ 38 ]. The primary outcome for this analysis was a binary variable defined as the presence of at least one identified HRSN.…”