Despite the fundamental importance of SDOH in health care, Johnson et al. (2022) reported that fewer than 23% of clinicians screen for them. Nehme et al. (2021) cited a 2019 survey of U.S. physician practices reporting one third did not screen for the five social needs of food, utilities, housing, transportation, and personal safety; about 75% screened for interpersonal violence only.

Reasons for not screening for SDOH include staff uncomfortable asking, tools not available, and resources or referral sources unavailable to address need ( Guo et al., 2020 ). Johnson et al. (2022) reported many of the same reasons as above and also added that clinicians had problems integrating screening into the clinic workflow. Nehme et al. (2021) cited evidence that although providers value the idea of social needs screening, they find it challenging when they cannot provide needed assistance for patients.

Those that do screen for SDOH as part of the patient assessment process have realized the benefits. Magoon (2022) asserted that SDOH screening is necessary to know and address social needs because patients may not volunteer information if they are not asked directly. Knowing the SDOH of patients allows nurses to work on interventions for positive change and advance health equity ( Johnson et al., 2022 ). SDOH data can also improve predictive modeling and increase understanding of patient life situations ( Cantor & Thorpe, 2018 ) as well as generate data for community action ( Nehme et al., 2021 ).

Clinicians who screen for SDOH have addressed identified needs using different approaches. Magoon (2022) reported that some practices have patient navigators or social workers to help patients with referrals to community resources, whereas others have on-site food pantries, in-clinic pharmacies, and/or laboratory services to address transportation barriers. Wynn et al. (2021) screened emergency department (ED) patients for food insecurity, provided nonperishable food bags, and connected patients to community resources. Montez et al. (2021) identified patients and families with food insecurity and offered resources including a bag of nonperishable food for several meals, a list of local resources, a meeting and follow-up phone call with an on-site care coordinator for assistance with resources, and referrals to federal nutrition programs.

Situation

A transitional care clinic (TCC) associated with a regional medical center in Guilford County, North Carolina, offers temporary follow-up care to patients who have no insurance and/or primary care providers (PCPs) after discharge from the hospital or ED. Clinic staff includes a medical director, two (one full-time and one part-time) nurse practitioners (NPs), a certified medical assistant (CMA), patient services associate, nurse case manager (CM), and a part-time licensed clinical social worker. The TCC saw an average of 68 patients per month during the first 7 months of 2022. Many more patients were scheduled but did not show for their appointments.

The TCC follows patients until staff can assist them in getting established with a PCP or local clinics that accept the uninsured, ideally within 90 days of their first TCC visit. Many of the patients who are referred to the TCC have challenges with transportation, housing, and paying for prescriptions and food in addition to their barriers to accessing medical care. The TCC provides coordination of care, follow-up laboratory examinations, medication assistance, and referrals to PCPs, specialists, and community resources. Staff also can offer some limited help with transportation to appointments by providing cab vouchers and bus passes. If patients are stable and/or able to establish with a PCP within a month or two, they may not return to the TCC after their first visit. In fact, many TCC patients have only one hospital follow-up appointment before being scheduled to establish with a PCP or clinic in the area.

Background

During 2020 and 2021, a local food alliance donated to the TCC more than 100 boxes of nonperishable foods for two to three meals. This donation was in collaboration with the FaithHealth (FH) community outreach program of the medical center. FH is a partnership between the health system, faith communities, and other providers to focus on improving health. TCC staff offered the boxes to patients who reported financial challenges or exhibited obvious need. However, there was no consistent screening process for food insecurity in place.

In fall 2021, the TCC CM viewed a webinar about Z-codes and started exploring ways to screen for SDOH at the clinic. The CM realized that SDOH assessment questions were already embedded in the electronic health record (EHR) with associated icons in the patient's storyboard, the left-sided vertical bar of summary information in the patient's chart. However, most of these items except for smoking history were not completed during hospitalization. The CM suggested that TCC staff should start to systematically collect data from all new TCC patients and document need in the EHR. Simultaneously, by late fall 2021, the TCC started running low on the donated food boxes.

Methods

Developing a Tool

After gaining approval from the TCC practice manager to add an SDOH screening tool to the new patient intake process, the CM met with staff to decide which of the EHR SDOH questions were most relevant for the TCC patient population. Staff wanted to keep the tool brief and focus on the most critical challenges for patients: barriers to paying for and accessing medication, transportation, housing, and food.

Staff chose seven SDOH questions directly from the EHR: one on general financial stress, two on food insecurity, two on transportation, and two on housing. The food questions ask whether the patient has run out of food in the past 12 months, and whether the patient has been worried that food would run out before he/she had money to buy more. Answering yes to either flags the patient as being food insecure. For every question there is an option of choosing not to answer. The seven-question tool covers two sides of a sheet of paper (see Appendix A ). Staff also created a Spanish-language version.

Implementing the Tool

In mid-December 2021, TCC staff began giving all new patients the seven-question paper questionnaire on their first visit to the clinic. Patients who have trouble reading the tool are assisted by TCC staff who read aloud the questions and answer choices for the patient and then fill in the tool with the patient's responses. The CMA collects the tool during rooming and shares with the NP. After the CMA and NP have reviewed the tool and offered a food box to the patient if applicable, the CM enters the data into the patient's EHR. For now the CM also scans a copy of the paper tool into the EHR for backup documentation. The tool takes only a few minutes for patients to complete, a few seconds for the CMA and NP to review, and a few minutes for the CM to enter into the EHR.

Partnering With the Faith Community to Organize Food Donations

Before January 2022 when the TCC ran out of food boxes, the CM had contacted the FH program of the medical center and learned there were no more boxes from the food alliance, but the program coordinator offered to reach out to area churches to see whether any would be able to provide food resources. TCC staff discussed with the coordinator what types of food and how much of each, type of container, and an estimate of how many units per month might be needed. Because many of TCC patients have diabetes and/or heart disease, staff wanted foods appropriate for low-salt and no-added-sugar diets, and easy-to-carry containers for patients who walk, bike, or take buses. Staff requested bags containing a jar of peanut butter, two cans of meat (tuna or chicken), brown rice, two cans of no-salt-added vegetables, and two cans of no-sugar-added fruit. Based on experience, TCC staff thought 10-15 bags a month would be a good start.

The FH program outreach coordinator located a church associated with a food pantry that expressed interest in partnering with the TCC. The pastor visited the TCC in early March, met with clinic staff, inspected storage space, and committed to supplying 15 bags per month. The first food bags arrived on March 15.

In addition to food, each bag contains a flyer identifying the church/food pantry donor, a community resource guide, and a patient evaluation form. The 16-page guide lists local resources including area food pantries, resources for seniors, emergency assistance, community meals, health care and mental health, and community gardens. The short four-question evaluation form asks whether the bag was helpful, requests suggestions for improvement, and includes a stamped envelope addressed to the TCC.

Food Bag Distribution

Staff offers bags to patients who answer yes to one or both of the two food questions. Staff notes on the assessment tool if a bag was offered, taken, and/or declined. Since collaborating with our faith community partner from mid-March through the end of July 2022, the TCC has distributed 52 food bags to patients.

Results

Documenting Food Insecurity: SDOH Assessment Results

Entering SDOH data into the EHR triggers some immediate responses: any identified insecurity changes the color of the associated SDOH icon to yellow or red (depending on severity) and if there is no insecurity identified the icon actually disappears from the EHR storyboard, although this information is still available in a window that opens by hovering with a mouse. SDOH results populate provider templates that have these built into them. SDOH data are also available for reports. The TCC sought approval from the institutional review board, which determined this to be a quality improvement project. Results demonstrate that in the first 7 months of 2022 between 34% and 71% of screened TCC patients reported food insecurity with a monthly average of 52% (see Table 1 ).

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Discussion

Evaluation of Food Bags

Not all patients who screened positive for food insecurity received food bags (see Figure 1 ). After mid-March when food bags were available, some patients declined bags; others left the clinic before staff offered a bag. Recipients who did receive food bags have told staff how grateful they were and at least one was tearful when voicing thanks. TCC staff records how many food bags have been distributed and saved results of a follow-up survey on the food itself. The TCC has received seven feedback/evaluation forms from the 52 bags distributed (13%), all of which had answered yes to Was this food bag helpful? Written suggestions for improvement included: "more nonperishable foods"; "more whole meal items like stew or mac & cheese"; and "put some snacks in it!" Additional comments included: "thank you so very much ... everything helps ... thank you for your kind hearts"; "It helps a lot ... thank you"; "people need bags like that"; and "I eat all the food & thank you!"

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Magnitude of Food Insecurity for TCC Patients

Since the TCC started screening for SDOH at the beginning of 2022, there have been only 3 out of 7 months when the average rate of self-reported food insecurity for new TCC patients has been lower than 50%. For as yet unknown reasons, March had the highest rate at 71% (see Figure 2 ). Because TCC patients are uninsured and/or have no PCP, it may not be surprising that they also have a higher rate of food insecurity than the general population. What is shocking, however, is the average rate of food insecurity of more than 50% for new TCC patients was noted in the first 7 months of 2022. This number is 2.7 times higher than the 2019 county rate, more than four times higher than the North Carolina rate for 2018-2020, and five times higher than the 2020 U.S. rate of food insecurity. Because there are no SDOH data prior to 2022 for TCC patients, it is unknown whether this rate of food insecurity is comparable to previous years or whether it correlates to post-COVID and current economic trends.

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Other Needs

An average of 28% of patients reported unmet transportation needs. Staff addresses transportation challenges as they arise: when patients report they cannot make their appointment due to lack of transportation, staff has bus passes or may arrange a cab ride with the taxi company partnered with the medical center. The TCC also collects information on housing needs but aggregated data are not available at this time. The TCC has requested these reports and is waiting for the medical center information technology department (IT) to build them.

Limitations of the Project

Guilford County had a population of 542,410 residents in 2021 ( https://www.census.gov/quickfacts/guilfordcountynorthcarolina ). The TCC has screened only 412 patients for SDOH in 7 months. This is a very small sample from a specific community and results may not be generalizable to other populations. The IT monthly reports are for unique patients so there are no duplicate individuals during each month, but patients returning to the TCC during the following month(s) are again counted as unique patients and it is unknown how this has impacted results.

At this time the TCC has not demonstrated improved health outcomes related to systematically assessing for SDOH and giving food bags and community resource information as interventions. The clinic screens only patients newly discharged from the hospital at their first appointments and the clinic lacks data for tracking changes in food insecurity for individuals over time. Staff is not collecting SDOH information for return visits because patients do not fill out registration/intake paperwork at return appointments. Additionally, due to the temporary nature of care offered by the TCC, many patients are seen once at the TCC and do not return; it is difficult to follow up on patient outcomes after they are discharged from the clinic. The TCC also has no data on whether patients were able to use community guide information about resources such as local food pantries.

TCC staff calls patients who have no-showed to reschedule appointments but in many cases have limited success in reaching them by telephone. Those patients that do reschedule after missing their visit have a high rate of failing to make their next appointment as well. It is possible that barriers preventing them from completing their appointments are associated with negative SDOH and their additional undocumented data may have added to the already high rates of insecurity in this population.

Next Steps

The TCC CM contacted the IT to question whether SDOH icons could be changed to green indicating no needs and keep them readily available in sight instead of disappearing from the storyboard, but learned that this is not possible in the EHR at this time. TCC staff may consider screening for SDOH at every appointment to track individual changes over time. The TCC might also consider adding a question to the patient food bag survey on whether the community resource guide was helpful in seeking additional food sources. TCC housing insecurity reports, once they are available, may be valuable sources of information for the community.

The TCC now has initial data on food insecurity of clinic patients, as well as more questions that need to be addressed, to present to the medical center and the community. The TCC can strengthen existing relationships with PCP practices and clinics to collaborate on improving and sustaining health outcomes. By working with the FH outreach program, the TCC can build additional relationships with local partners and start conversations on how to address demonstrated needs. Correlating TCC SDOH needs and interventions with hospital readmission rates and tracking successful referrals to community resources would be ways to start measuring health outcomes.

Conclusion

There has been a lack of SDOH data in the EHR of a TCC in Guilford County, NC. TCC staff developed and implemented a simple screening tool for collecting information to enter into embedded SDOH assessment questions in the EHR. Staff started collecting SDOH information on new patients at the end of 2021. Results show that 52% of new TCC patients reported food insecurity during the first 7 months of 2022. This rate is significantly higher than the rates for the county, state, and country between the years of 2018 and 2020.

In order to start to address this newly documented need, the TCC collaborated with the medical center FH program to partner with an area church to provide nonperishable food to patients. Offering food bags is not going to solve the problem of food insecurity, but it is one attempt to address an immediate need. Patients have expressed appreciation for the bags, both verbally and on the written food evaluation surveys.

The SDOH data collected from new TCC patients can now be used to demonstrate need for action to the medical center and the larger community. In addition, the success of the TCC in launching a short and simple process for SDOH screening could serve as a model for other clinics and departments that would like to collect this information. Increased SDOH documentation in the EHR can generate more data for understanding patient situations and working on interventions to affect positive change and advance health equity.

References

Berkowitz R., Bui L., Shen Z., Pressman A., Moreno M., Brown S., Nilon A., Miller-Rosales C., Azar K. (2021). Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic. BMC Family Practice, 22(1), 256. https://doi.org/10.1186/s12875-021-01598-3 Bibliographic Links [Context Link]