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A qualitative study recently published in PLOS ONE examined how health clinics serving women of reproductive age and young children screen for social risk factors, refer patients to community organizations, and offer recommendations for improving the process.
There’s a lot more to health than what happens at the hospital or clinic. Factors like where someone lives, access to healthy food, job opportunities, education, literacy skills, and more can influence their ability to prioritize their health.
Our newly published research examined how clinics in the Washington, D.C., area are working to understand the impacts of these social determinants of health on mothers and babies and how the clinics understand patient needs and referrals to resources and services that can help.
Studies have estimated that the care patients receive in the clinic or hospital is responsible for about 20% of health outcomes. Other factors, such as social determinants of health, including contributors such as genetics and social risk factors like food and housing insecurity, determine the other 80%.
Addressing these social risk factors may help improve maternal and infant health, especially in places like D.C., where disparities are high. The District of Columbia has some of the nation’s highest death rates due to pregnancy or childbirth complications. The maternal death rate in D.C. is about 1.5 times higher than in the rest of the country, and 90% of those deaths are among Black birthing individuals.
We know we can do better for D.C. families, and evidence suggests we can make a difference by better understanding individual social needs, adjusting care as needed, and connecting patients with appropriate services. The first step in our study was to understand how social risk factors were being assessed and addressed across various settings.
Interviews with patients and clinic staff
We conducted our qualitative study from December 2020 to March 2021. Gathering different perspectives helps us fully understand the problem and identify the intersection of patient and provider needs where solutions can be found. We spoke with various healthcare staff and patients to fully understand how social risk factor screening and referrals are conducted and what experiences were like for participants.
Our researchers spoke with healthcare team members in four clinics focused on OB-GYN, family medicine, and pediatrics, including:
- Front-line staff like front desk staff, clinic managers, and social workers
- Advanced clinical practitioners such as physician assistants, nurse practitioners, midwives, and medical doctors
- Employees of a community-based organization that partners with MedStar Health as part of D.C. Safe Babies Safe Moms, a collaboration that connects patients with maternal and infant health services.
Each clinic invited pre-natal or post-partum patients who visited within the last three months to discuss their experiences. Seven patients reported their race as African American, and eight used public insurance. In total, we conducted in-depth interviews with nine patients and 18 staff.
Related readings: Safe Babies Safe Moms Program Sets the Stage for Better Outcomes
Results: Different methods, similar patient care goals
While all clinics were screening for social risk factors among targeted populations within their clinics, each had a unique process. Some asked patients to complete questionnaires on paper or electronically in the waiting room. In contrast, in others, the provider asked questions during the visit, or front desk staff called patients who had not completed forms online before the visit. Only one clinic used a screener embedded in the patient’s electronic medical record. The frequency of screening also differed by the clinic.
Our research identified several factors that make screening for patients’ social needs more difficult and ways clinics work to overcome challenges. We identified improvement opportunities in these processes that can help better assess and address social risk factors.
Challenges to successful screening and referral
The clinics we studied encounter screening challenges that are too common in many healthcare spaces, including limited staff and resources. These include:
- Too few staff to screen all patients for social risk factors
- Cultural or language barriers
- Time needed to complete the screening: Some patients could not wait long after their medical appointment.
- Screening for needs that can’t be addressed: Some participants mentioned that they were hesitant to ask about needs like housing if there was not a service to address that need
- Some patients were uncomfortable discussing their social needs due to perceived stigma.
- Challenges with follow-up and resource access: Patients who received information did not always follow up independently, especially when they were not interested in the solution offered.
When referring patients to social resources and following up, clinics faced obstacles, including:
- The time and staff needed to document screening in multiple places, like the doctor’s notes and a tracking spreadsheet
- Lack of financial reimbursement to follow up on social risk factors or to connect patients with a community resource
Responses to identified needs ranged from providing patients with educational handouts and contact numbers for service providers to case management with ongoing follow-up with a social worker or mental health counseling.
Making progress despite obstacles to screening
All the clinics involved in our research also had good news to share. Despite the challenges, staff at all levels worked with patients to support their social needs.
Some things that were working well included:
- Helping patients understand the benefits of screening for social risk factors and that they may be asked questions about them during their maternal health visit
- Some clinics provided tangible benefits to patients, such as free diapers. These incentives were well-received by patients.
- Co-location of services to address identified needs.
- Medical translation services to help patients and staff communicate
- A welcoming clinic culture, including signage and information about social risk factor screening
- Having patients complete screening questionnaires at home before their visit or in the waiting room.
Some clinics used electronic tracking forms to manage information flow when following up with patients and making referrals.
Some clinics developed a map of where to direct patients for help based on their needs. Some services require referral to a social worker or other support services, while others could be addressed in the clinic, like mental health or substance abuse, especially where behavioral health was co-located within the clinic.
Recommendations for process improvements
During our research, some common suggestions for process improvements to help clinics better assess and address the social risk factors of individuals of reproductive age including:
- Shorter questionnaires
- More screening before patient appointments, at home, or in the waiting room
- Additional training for staff conducting screenings on discussing sensitive social risk factors
- More resources translated into languages other than English
- Screenings that are patient-centered to reduce discomfort with sensitive topics
To help improve follow-up processes, our research recommends:
- Greater integration of social needs screening into electronic health records to facilitate information sharing
- Improvements in referral tracking processes
- Community-based resources are housed within the clinic so that patients can access these necessary services in one visit.
Next steps: More research, lessons learned, and policy progress
During the data collection period, each clinic was revisiting the implementation of social risk factor screening to iteratively improve processes for understanding social risk factors and their impact on care and continue to test new delivery modalities and processes.
This research has allowed us to discuss social risk factors screening in health clinics serving women of reproductive age and young children. With dedicated staff and processes, these clinics can identify practices that work well, share lessons learned, and continue improving patient services. Within the MedStar Health system and with community partners, providers are working to adjust care and provide appropriate referrals to community-based resources.
Reimbursement is among the most profound policy challenges to providing important social risk factor screening in many health clinics in D.C. In busy clinics with a high volume of patients, it is challenging to commit staff to address social risk factors meaningfully.
Hospital systems or external grants often fund screening and referral work, but these are temporary solutions. Additional studies will help show how screening and referral for social risk factors impact health outcomes, which can help make a case for reimbursement. Legislative momentum toward making changes has already begun.
This research builds a foundation for our ongoing work to address the impacts of social determinants of health on our patients’ maternal and infant health outcomes in partnership with our colleagues throughout the region.