Screenings for Social Determinants of Health Need to Be Tailored to Clinics.

An estimated 70 percent of the variation in healthcare outcomes is attributable to social determinants, but it is only in recent years that healthcare settings have begun formally looking at these factors to better understand and treat patients.

Now, a new study co-authored by School of Public Health researchers finds that these social determinant screening systems need to be tailored to individual clinics.

The study, published in the Journal of the American Board of Family Medicine, looked at community health centers in Boston that use a standardized system for social determinant screening in their pediatric practices and found a great deal of variation in practice, as well as in opinions about what helps or hinders the process.

“In our focus groups, there was little agreement about whether provider perspectives, work flow, prior experience, site resources and staffing, and sustainability were barriers or facilitators for implementing the screening, because they were all seen as barriers and facilitators depending on the respondent, ” says study senior author Mari-Lynn Drainoni, research professor of health law, policy & management. “This suggests that tailoring processes and including staff and providers in implementation decisions may overcome issues with time, work flow, and knowledge.”

For the mixed-methods study, the researchers looked at the social-risk screening practices at 13 Center for Community Health Education Research and Service (CCHERS) Boston community health centers. Three of those practices participated in the WE CARE screening and referral pilot. Previous research has shown that the pilot program improved health outcomes for mothers and young children at those three health centers.

The researchers requested and analyzed all of the screening materials from the 13 centers, and conducted focus groups with nine physicians, three nurses, and 14 medical assistants from the three centers that participated in the pilot screening and referral program.

They found that, while all of the community health centers were screening for social determinants, they were not all screening for the same ones, or screening for the same determinants in their adult patients and in pediatric patients. The average health center only screened for 8 of the 16 domains in the pilot’s standardized screening, and housing was the only domain included in the screenings of all 13 centers.

The focus group participants had generally positive opinions of the screenings, including saying that the screenings helped patients (or the guardians of very young patients) open up about their needs. Because the health centers primarily serve vulnerable populations, the participants also said that they felt the screenings formalized some of the work that they were already informally doing with their patients. Some participants expressed doubts about the frequency of the screenings, insufficient time and resources for the screenings and referrals, and confusion about how and when to help a patient connect with other services—but others expressed opposite perspectives. The authors noted that perspectives mostly differed from center to center, rather than between providers and staff.

“We found no agreed on barriers and facilitators for what could substantially improve the implementation of screening and referrals,” the authors wrote. Instead, they wrote, the study shows that, while the standardized screening was created and implemented by public health practitioners for all of the health centers, it would be more effective to work with providers and staff to tailor best practices to each individual center’s needs, work flow, and resources.

The study was co-authored by students Yareliz Diaz and Grace Yoon; Martin Charns, professor of health law, policy & management; and Arvin Garg and Michelle Pellicer of the Department of Pediatrics at the School of Medicine and Boston Medical Center.

The study’s lead author was Elena Byhoff of Tufts Medical Center and Tufts University School of Medicine.

—Michelle Samuels