It has long been recognized that social forces—poverty, class, gender, racism, war, and social policies—have a profound effect on disease: on who gets ill, the spread, and course of illness. Rudolf Virchow, a German physician, is credited with not only being the founder of pathology and cellular biology but also the father of social medicine. He advanced the idea that disease is not purely biological, but can be caused, spread, and exacerbated by social factors. To combat disease, Virchow suggested scientific medicine should be combined with population health, public health, and politics. In 1848, for example, he concluded that the cause of a typhus outbreak was largely due to wretched living conditions and that such an epidemic could be very simply prevented through “education, with its daughters, liberty and prosperity ….” With these insights, Virchow and others committed to social justice brought about stunning improvements in health in the 19th century, long before the advent of antibiotics and other miracles of modern medicine, through social policies addressing poverty, improving public sanitation, as well as working and housing conditions.

Contemporary social medicine advocates still recognize inequality as a potent factor underlying disease and have been very influential globally. Tackling the HIV pandemic, for example, has required not only understanding the biology of the virus but also supporting the rights of the poor, women, sex workers, children, drug addicts, and sexual minorities and challenging systems that put treatments out of the financial reach of patients.

In the United States, Virchow’s insights have not been widely incorporated into social policies or medical practice. Currently, the US programs created to address social conditions that undermine health are associated with the safety net and are often reviled as “handouts.” Issues such as poor housing conditions or food insecurity, which arguably would be more effectively addressed in the arena of public policy, present themselves as powerful issues undermining the health of patients. In the absence of an integrated social approach to health, clinicians struggle to care for patients suffering from the ill effects of their social vulnerabilities.

Advocating for patients’ social and legal needs, whether in the context of clinical encounters, clinical systems, or broader political contexts, requires specific training and tools (see Chapter 8, Advocacy). Examples of patient-, institutional-, and community-level interventions addressing social and legal determinants of health are provided in Table 9-1.

In this chapter, we focus on practical, clinic-based strategies to address social determinants of health at the patient and clinical system levels within the US health-care system. These strategies require both redesigning clinical systems and training the health-care workforce.

In 2012, the “blindside” of US health care was revealed by a nationwide survey of physicians assessing providers’ capacity to address patients’ social and legal needs. The survey found that 9 of every 10 clinicians working in safety net settings believe that social factors strongly contribute to health-care outcomes, but 80% report lacking the capacity to address these factors.¹ The gap between health providers’ awareness of social needs and capacity to address them contributes to delays in diagnoses, less effective, inefficient (and therefore costly) health-care delivery and utilization, health disparities, patient dissatisfaction, and clinician burnout.²

Despite the pervasiveness of social need and its impacts on both child and adult health, patients’ social, environmental, and legal needs often remain unaddressed in clinical encounters. Addressing these needs, however, may bring significant health benefits. Connecting food insecure patients and families to community food resources and food stamps, for example, may bring about long-term improvements in individual and community health. Studies have demonstrated the association of food insecurity, for instance, with increased HIV risk behaviors and, separately, increased hypoglycemia-related hospital admissions at the end of the month due to the exhaustion of food budgets.^3,4

Socioeconomic indicators can also enhance the utility of specific clinical screening recommendations. Fiscella et al incorporated patient income into 10-year Framingham Risk Score calculations, and found that doing so better identified patients at risk of developing cardiovascular disease than did traditional calculators.⁵ Furthermore, adjusting for education improves the accuracy of the Mini-Mental State Examination in predicting disease likelihood.⁶ As knowledge about health impacts of interventions to address social and legal determinants grows, both the health-care quality and long-term financial ­benefits of adopting these interventions will become increasingly persuasive.

Many forces in the US system of health—from the historically separate development of our public health system and our medical schools to more recent health-care reimbursement systems that reward volume of services over value for money spent⁷—have stymied addressing social determinants of health both in clinic settings and the health-care system more generally.⁸ The passage and implementation of the 2010 Patient Protection and Affordable Care Act (ACA) has led a number of payers in the public and private sector to explore ways of shifting from volume-based to value-based payment models that support continuity and coordination of care. Providers are being asked to reorganize and redesign the way they deliver care using models such as the Patient-Centered Medical Home (PCMH). Since social, legal, and environmental factors are major determinants of health outcomes, particularly among vulnerable populations, redesign efforts that seek to optimize value in clinical systems must incorporate methods to address relevant social determinants.⁸

Clinic system redesign is the systematic process of analyzing current clinical operations and planning new operational systems to improve the efficiency, quality, and effectiveness of patient care.^9,10 In US primary care settings, the components of clinic system redesign have been widely spread through financial incentives offered by a number of state and commercial payers.^11,12 Some categories of redesign that garner enhanced reimbursement are related to patient-centered access; team-based care; population health management; care management and support; care coordination; and care transitions.¹³ Methods to address upstream social, environmental, and legal needs can align with and support clinic system redesign efforts, helping clinic systems meet new standards such as those established for PCMH and other models of coordinated care delivery (e.g., the patient-level Ambulatory Intensive Care Unit model or the system-level Accountable Care Organization model).

A typical patient-centered clinic workflow can be a helpful framework to consider ways to understand and address social determinants in clinical settings that serve vulnerable populations. Specific clinic functions in a typical workflow include screening, triage, evaluation and management, documentation; referrals, and follow-up. Clinical tools that address social determinants of health often seek to enhance one or more of these ambulatory patient-care functions.

SCREENING FOR SOCIAL DETERMINANTS OF HEALTH

There are two key operational questions to answer when considering screening for social determinants of health in clinical settings: “Which social determinants of health should we screen for?” and “How will we screen for these social determinants of health?”

Choosing which social determinants of health to screen for in a clinic setting can be challenging. To balance the need for useful, locally relevant social factor data that can inform patient care with the need for useful population-level data that can aid public health and research efforts, policymakers and clinical providers are encouraged to capture “Core” (foundational) measures and “Custom” (flexible) measures related to social determinants of health.

“Core” measures collected by all clinical sites

Clinics should first capture “Core” social needs and characteristics relevant to the care of most, if not all, vulnerable patient populations receiving care in the system. We recommend capturing “Core” socio-demographic domains described by a committee of the Institute of Medicine in 2014 (Box 9-1).¹⁴

“Custom” measures, clinic and population specific

Clinics should then take steps to capture “custom” measures tailored to community and clinic priorities that reflect local social determinants of health. These might include such issues as screening for risk of dropping out of school in adolescents, pesticide exposure in agricultural communities, history of political violence in refugees, or food insecurity in low-income, urban populations.

Choose validated screening tools when possible

A variety of screening tools to identify social, legal, and environmental needs are currently in use in clinical practice. They include validated, published tools developed by researchers as well as unpublished, “home-grown” surveys and questionnaires developed by frontline clinic staff eager to respond to perceived unmet social needs. Some tools are specific to a particular social factor such as food insecurity or occupational exposures and often reflect clinic projects supported by external funders with specific interests in a particular social need.^15,16,17 Other tools are more comprehensive, covering several social, legal, or environmental domains (see www.HelpSteps.com).¹⁸ A compilation of social screening tools is currently maintained by an online learning collaborative organized by HealthBegins (http://healthbegins.ning.com/page/social-screening-tool). The “Core Competency” at the end of this chapter includes specific items and references to several social screening tools used around the country.

Based on population needs and clinic priorities, many more topics could be considered, including domains related to social isolation, stress, violence, and literacy. The scientific validity of individual questions varies. Some questions such as those related to housing and food security have been well studied, but wide-scale adoption of comprehensive screening tools could be strengthened by improved validity testing to make sure that these questions maximize accurate disclosure on relevant, sensitive social and legal issues.

To improve institutional “buy-in” and the diversity of input, the screening selection process for “custom” measures should be participatory and involve representatives from different clinic and community stakeholder groups, including patients, clinicians, health information technology staff, billing/coding staff, social workers, care managers, enabling service staff, outreach/community health workers (CHWs), and community-based social service providers and advocates.

Community-specific social needs

After identifying their community catchment area, clinics are encouraged to contact local hospitals, public health departments, county agencies, nonprofit social service providers, advocacy organizations, and/or academic research institutions to obtain data and reports such as Community Health Needs Assessments that reflect local, population-specific unmet social needs. Clinics can also use web-based survey software, key informant interviews, focus groups, and other methods to collect primary data from community partners.

Community-specific resources

Clinics often choose not to screen for unmet social needs due to a lack of awareness of local community resources that can address them. In contacting local partners to identify unmet social needs as indicated earlier, clinics can also generate and update community-specific social resource maps. Clinics should strive to select “Custom” social screening measures for which local corresponding resources have been identified.

Clinic priorities

Patients with health problems or costly utilization patterns that are caused or exacerbated by unmet social needs can be a challenge to clinics that are striving both to improve care for individuals and populations and decrease costs. The selection of “Custom” measures for social needs screening should reflect the clinic’s need to improve care and outcomes for specific vulnerable and challenging patient populations.

Optimize use of the Care Team

As clinics shift to team-based care models, methods that solely rely on the clinician to screen for core and custom measures related to social determinants of health are not recommended. Instead, consider redesigning the workflow of social screening to distribute the collection of core and/or custom social measures among other care team members and across different steps in the patient experience. These steps include pre-visit; patient registration/check-in; waiting room; vitals; in exam room/pre-clinician encounter; clinician encounter; post-encounter/in-room; lab; pharmacy; care coordinator, and scheduling follow-up.

Explore Electronic Health Record (EHR) and non-EHR–based tools

When possible, clinics should work with electronic health record (EHR) vendors, clinical EHR champions, in-house information officers, and other information technology staff to build social screening items into their EHR. Alternatively, other tools—such as self-directed and/or staff-­assisted surveys via in-person or phone-based interviews or secure SMS, email systems, kiosks, or other standalone web-based software-as-a-service platforms—can be used to capture key data on unmet social needs (see HelpSteps.org; Healthify.us).

Triage

The degree to which screening tools are successfully integrated in clinical practice depends on several ­factors, including buy-in from clinic and community stakeholders as well as the clinic’s ability to triage or sort patients to appropriate resources using these screening tools. Appropriate triage of unmet social needs identified in clinic settings should align with other practice-based triage processes. These should ensure that the clinic’s written, posted triage policy is updated to include social, legal, and environmental needs and is developed and signed off by relevant clinic leaders, including medical, nursing, social work, quality, and legal supervisors. This policy should include protocols for “warm handoffs” between clinic staff when possible, as well as random chart reviews and other quality assurance mechanisms.

Clinic staff will also need to incorporate the triage of unmet social needs into existing patient care workflows or to create a parallel triage process that is independent of the patient–clinician encounter. Depending on the social need, patient population, and clinic priorities, clinics may choose to have a clinician involved in the triage process to review any health-related social needs. This can be facilitated through several mechanisms, including pre-visit chart reviews; team huddles; or the integration of social workers, health educators, and/or CHWs into the care team and patient visit. Alternatively, tools such as EHRs with decision-support software can automate social needs triage, linking patients to community resources without the need for clinician discussion through printed handouts, SMS, phone calls, or email. The use of computerized order entry, standing orders, and decision support software can improve the efficiency of social needs triage.¹⁹

EVALUATION AND MANAGEMENT

While some clinics may decide to create a triage process that does not require that clinicians directly address social needs, it is important for clinicians and care team members to understand the ways in which social, environmental, or legal needs can have a direct impact on patient health and medical decision making. This understanding can inform and improve evaluation, diagnosis, and the effectiveness of treatment plans.

As clinically relevant information related to social determinants of health continues to expand, care team members, including clinicians, will have greater opportunities and professional obligations to incorporate this information directly into their evaluation of patients’ presenting complaints and symptoms. As part of continuous quality improvement (QI) efforts, health-care professionals should avail themselves of emerging tools, continuing educational opportunities, and practice-based learning collaboratives to stay updated about the latest evidence regarding the complex interplay between social determinants and patient and community health.

Clinic system operational efficiencies also can improve management and treatment of health-related social needs. For example, clinicians involved in the medical–legal partnership at Boston Medical Center (BMC) routinely use templates to quickly generate letters for patients who are facing utility shut-offs (see Case Study), need supporting documentation for disability applications, require special education accommodations at school, or need to establish guardianship to facilitate caregiving.

DOCUMENTATION—CODING/CHARTING/BILLING