Nurses’ role in addressing social determinants of health BY VICTORIA

Nurses’ role in addressing social determinants of health BY VICTORIA TIASE, MSN, RN-BC; CATHRYN DEGRAFF CROOKSTON, BSN, RN; ANNA SCHOENBAUM, DNP, MS, RN-BC; AND MADELYNN VALU, MPH, RD Abstract: Nurses have a vital role in ad­dressing social and health inequities to promote quality healthcare for all. This ar­ticle discusses the tools to screen for social determinants of health (SDOH) and key considerations for nurses and nurse leaders to advance the integration of SDOH infor­mation into their workflows. Keywords: SDOH, social determinants of health, health disparities, health equity Up to 80% of a person’s health is determined by socioeconomic fac­tors, health-related behaviors, and environmental conditions.1 Identi­ fying and helping patients manage these social determinants of health (SDOH) should be key parts of proactive patient care. In the past, data about SDOH were either un­known or had fallen outside of the traditional purview of hospitals and clinics.2 To collect and exchange SDOH information, methods were developed to screen and collect data electronically. In 2014, the National Academy of Medicine cre­ated standard social and behavioral domains for primary care settings highlighting the importance of capturing these domains electroni- cally.2 This involves implementing tools to support SDOH assessment by healthcare teams and standard­izing the process for conducting SDOH assessments within roles and responsibilities. Multiple national medical profes­sional associations recommend social risk screening and documentation in healthcare settings because of the compelling evidence that social risks are associated with poorer adherence to treatment plans, worse health out­comes, and increased costs of care.3 Despite these recommendations and growing national attention for the health impacts of SDOH, the uptake and prevalence of healthcare-based screening for service delivery are highly variable, and existing efforts to assess patients’ SDOH have typi­cally been ad hoc.4 The Centers for Medicare and Medicaid Services developed the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool to address the critical gap between clinical care and community services.5 This unique 10-question tool assesses five key domains of health-related social needs, collecting a breadth of infor­mation that increases the likelihood of identifying significant needs.5,6 The tool can also be integrated into multiple clinical workflows and ac­cessible across diverse patient popu-lations.6 In a study evaluating the accept­ability of the AHC HRSN Screening Tool among adult patients and adult caregivers of pediatric patients, a sizable majority of participants found the tool appropriate across di­verse healthcare settings.7 They also reported being comfortable with having the results integrated into electronic health record (EHR) sys-tems.7 Screening acceptability varied among subgroups based on prior exposure to social screening and assistance, trust in clinicians, experi­ence with healthcare discrimination, and recruitment from a primary care setting or healthcare facility with more patients who are uninsured or have public health insurance. These variations were small to moderate, and both screening appropriateness and comfort with EHR documenta­tion were high for all subgroups. These findings suggest that patient acceptability is not likely a major barrier to SDOH screening imple-mentation.7 Given these findings, barriers could be more closely as­sociated with technical and logisti­cal factors such as workflow, data collection, review and response, screening tool implementation, and referral mechanisms. Additionally, the United States is in the midst of a deeply problematic nursing shortage that is expected to continue through 2030.8 This has created a major imbalance in workloads for those remaining in the job and resulted in less time, incomplete communica­tion, and thus, lapses in continuity of care.9 This article reviews the SDOH assessment process and screening tools used in the context of nursing workflows and discusses key consid­erations for nurses and nurse leaders to advance the integration of SDOH information into clinical care. Screening tools SDOH assessment tools are used to identify social risks that reflect a per-son’s unmet social needs. Although differing in methodology, content, and follow-up procedures, these tools often focus on key SDOH do-mains.10 These commonly include housing, food, transportation, em­ployment, education, financial strain, and personal safety.11 Although an organization could develop and validate its own ques­tions, organizations often find it most expedient to implement existing and validated assessment questions or tools. Many SDOH screening tools are available.11-14 However, there is a lack of national guidance on the use and effectiveness of these tools (see Common SDOH screening tools).15 Ac­cording to the National Committee for Quality Assurance (NCQA) Social Determinants of Health Resource Guide, organizations must make ad­dressing SDOH a strategic priority then design an SDOH assessment program involving these four main workstreams:16 ‘ Whom to assess: Determining whom to assess might depend on an organization’s resources, bud­get, and current workflows. Some organizations begin with universal assessments, while others start with high-risk individuals and expand to a broader scope once workflows are optimized. ‘ What to assess: There are three dif­ferent approaches to SDOH assess­ment. Strengths-based assessment is often used in behavioral health and focuses on measuring a person’s pro­tective factors (such as social support system, access to resources) that help them thrive in adversity. Risk-based assessment and needs-based assess­ment are commonly used in medical environments. They focus on captur­ing individual characteristics that put a person at risk for poorer physical health (such as poverty, sexual orien­tation) or an individual’s immediate unmet social needs. ‘ What questions to ask: Although most readily available SDOH as­sessment tools include screening questions on food, housing, trans­portation, and finances, limited evidence supports screening for spe­cific SDOH factors. When choosing specific questions, consider the social risks in the population served and available local resources. ‘ How to implement the assessment: A variety of individuals may have responsibility for SDOH assessment including social workers, commu­nity health workers, physicians, care managers, nurses, transportation pro­viders, clergy, housing assistance pro­viders, and other service providers. Methods used for collecting informa­tion have included verbal in-person, verbal remote, written assessment, and through a kiosk, computer work­station, smartphone, or tablet. Research on the effectiveness of screening in improving patient outcomes has been divided into two categories: (1) screening for single domains of social risk and (2) simultaneously screening for multiple domains of social risk.17 Given that social risks tend to aggre­gate, screening for multiple SDOH domains would seem to make more Common SDOH screening tools Screening Tool Developed By Features Protocol for Responding to and Assessing Patient’s Assets, Risks and Experiences (PRAPARE) National Association of Community Health Centers (NACHC) Consists of a set of national core measures and a set of optional measures for community priorities Informed by research, the experience of existing so­cial risk assessments, and stakeholder engagement Aligns with national initiatives prioritizing social de­terminants (such as Healthy People 2030), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System11 Health-Related Social Needs (HRSN) Centers for Medicare and Medicaid Services (CMS) Developed as part of the Accountable Health Com-munities Model to determine if systematic screening for health-related social needs affects total healthcare costs and health outcomes Helps providers find patients’ needs in five core do­mains including housing instability, food insecurity, transportation problems, utility help needs, and inter­personal safety4 The Health Leads Social Needs Screening Toolkit Health Leads Provides a comprehensive blueprint for organizations seeking to identify and screen individuals for adverse social determinants of health Includes updates based on the latest social needs research, lessons learned from long-standing screen­ing programs, and feedback from clinicians and healthcare providers12 HealthBegins HealthBegins Contains 28 questions assessing five domains: eco­nomic stability, education, social and community context, neighborhood and physical environment, and food13 sense; however, there is a much larger body of research related to screening for single domains of so­cial risk, particularly intimate part­ner violence, suicide, and child and elder abuse.18 A 2017-18 National Survey of Healthcare Organiza­tions and Systems that estimated the prevalence of screening for five social risks (food insecurity, hous­ing instability, utility needs, trans­portation needs, and interpersonal violence) concluded that screening across multiple domains is not yet common in clinical settings.19 Once an organization has decided to screen, the fourth workstream becomes critical: How to implement the assessment. Although many community-based organizations may initiate assessments or the patients themselves may choose to complete a digital screening tool, this article focuses on healthcare organizations as the point of origin of assessments. Working in the most trusted pro­fession, as reported in the most recent Gallup Honesty and Ethics poll, nurses are in a unique position to screen for SDOH.20 One study found that nurses feel knowledgeable and confident in discussing certain deter­minants of health, particularly issues related to access to healthcare.21 With an integrated screening tool acces­sible from the EHR, nurses can collect SDOH data within their current docu­mentation workflows. Having this in­formation can be valuable to support patient care and discharge processes. All aspects—including confidence in discussing SDOH, knowledge about the importance of collecting this in­formation, and proficiency in using an integrated screen tool—must be addressed with nursing workflows in mind to increase adoption and use. The SDOH screening expectations and frequency should be outlined in the organization’s standard processes (for example, during triage or intake, 34 l Nursing2022 l Volume 52, Number 4 www.Nursing2022.com Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. prior or after the initial appointment, at discharge, and on every home visit) and part of nursing orientation processes. The frequency of SDOH screening must be clearly outlined, noting that it may be adjusted ac­cording to the patient’s risk level and ongoing needs. As SDOH data are modified over time, the creation of an electronic notification within the EHR would be beneficial to alert care team members when new data are present. Procedures for successful screening should consider patient education on the reasons for collect­ing data, how it will be used, and who will have access to the data. Access to and integration of SDOH data Using collected SDOH data, nurses will have the ability to identify patients at risk for negative health outcomes and connect patients with needed services. Based on the socio­economic and environmental needs and risks of the patient, SDOH data can be reviewed regularly along­side the plan of care to address the patient’s needs. Easy access to and visibility of SDOH data facilitates referrals to community services and supports a greater understanding of the factors that affect health. Information overload has been a critical issue for clinicians, who often have limited time to review the vast amount of data that has not been translated into relevant informa­tion when they are needed.22 The collection and documentation of the information itself also increases responsibility and workload of nurses, who are often tasked with administrative burdens that would otherwise be outside of their job de-scriptions.23,24 Accessing information at the proper point in the clinical decision-making process is critical.25 To optimize its use, SDOH data must be integrated into clinical workflows in a way that supports the efficient use of the information without creat­ ing an undue burden on nurses. Common approaches to imple­menting clinical decision support tools, such as identifying the needs of the users and what the system is expected to do, may be useful in inte­grating SDOH data into workflows.26This includes the use of the EHR in presenting the right data in the right place to the right clinician at the cor­rect point of the clinical workflow.27A thorough understanding of SDOH information needs in settings and situations may also contribute to its optimal integration into workflows. To decrease the cognitive burden of nurses, machine learning algo­rithms can be used to build SDOH data models. These types of predic­tive and prescriptive analytics can provide new insights into the interac­tion between social conditions and health outcomes in specific patient populations. A recent study in the American Journal of Managed Care found that applied machine learning can be used to predict patient utiliza­tion of inpatient and EDs based on their SDOH.28 These findings can be applied on a wider scale and could positively impact patients, the com­munity, and the health systems.28 Interoperability Nurses must also explore the level of interoperability or the amount of SDOH data exchange between healthcare organizations and external stakeholders, particularly its impact on nursing workflows. It is important that SDOH data can be shared and ex­changed with community partners and other healthcare systems to develop a system of holistic and longitudinal care for patients, primary care providers, case managers, and other healthcare workers who may require access to SDOH data. Data flows should be examined, and where possible, SDOH data should be reused and shared for optimal use (see SDOH screening in clinical practice: Use cases).29 Recommendations for nurses Although nurses routinely consider the elements of SDOH in clinical practice, the systematic collection and established procedures for use are not commonplace in healthcare organizations.30 Nurses can take the lead in education, research, and prac­tice by partnering with community organizations. Nurse leaders should participate in organizations, task forces, and committees at the local, state, or national level to advance standards, policies, and incentives supporting the collection, use, and sharing of SDOH data.31 Nurses can cultivate a culture that promotes the importance of SDOH among health­care professionals and the integration of screening tools and visualization of SDOH data into existing workflows. Finally, nurses must collaborate with community agencies and healthcare entities to define how SDOH can be fully integrated into patient care (see Steps to address SDOH). For clinical nurses who want to understand how SDOH data can be integrated into their healthcare organization, consider the following actions: Learn more about the organization­al policies and procedures for SDOH. Explore EHR documentation to identify where SDOH data may al­ready be collected and the best loca­tions to review data. Encourage colleagues to have dis­cussions with patients to understand their comfort levels with sharing SDOH information. Support and advise organizational plans to implement SDOH into nurs­ing workflows. Identify opportunities to conduct a nursing inquiry for SDOH inter­ventions. Establish ways to triage support based on individual responses to SDOH-related questions by involv­ing interdisciplinary team members such as social services, nutritionists, and mental health professionals. Conclusion Integrating SDOH data into nursing workflows has the potential to im­prove patient care. Nurses are well-positioned to advance operational ef­forts to incorporate SDOH screening tools and information into new care models that prioritize the efficient use and exchange of such information to adequately meet patient needs. The increased involvement of nurses and nurse leaders in the use of social risk 4th Clinical Objectives and Write-up-SDOH On your fourth clinical day, explore the following areas. Please answer all questions below, as well as complete the personal reflection questions. (This applies to all clinical locations) For this assignment you will be expected to complete some pre-clinical reading related to SDOH. Read this article prior to clinical as it will assist with your reflection. Social Determinants of Mental Health Good mental health is integral to human health and well-being. A person’s mental health and many common mental health disorders are shaped by various social, economic, and physical environments operating at different stages of life. Certain population subgroups are at a higher risk for mental disorders because of greater exposure and vulnerability to unfavorable social, economic, and environmental circumstances, interrelated with gender. Collaborate with your preceptor and ask these questions: Ask your preceptor what they know about social determinants of health as it relates to their experience working within Mental Health nursing. (Show them the info graph from above for a quick refresher). Do they complete any assessments with patients exploring their SDOH? Can your preceptor think of a patient they’ve cared for where the social determinants of health for that patient were impacting their mental health? (food insecurity, housing insecurity, lack of healthcare access/insurance, discrimination etc.) Clinical Write-Up (Due by Sunday at 2359) Write a brief reflection (no more than two pages) about your clinical rotation. Please include these items: What are the most common social determinants of health you’ve seen impacting patients, peers or your community? (List at least two) Do you think these barriers could negatively impact the person’s physical or mental health and how/why? Using the table above and the contents of the article, discuss what you feel are the most important (priority) SDOH’s to address? (There is no right or wrong answer, this is just your personal thoughts) Consider and reflect on this scenario: The nurse is working with a newly admitted patient to the acute psychiatric unit where they work. The patient had previously been diagnosed with major depressive disorder and was experiencing suicidal ideation when they voluntarily sought admission to your facility for help. The nurse has completed a brief SDOH assessment as a part of the admission process and the patient screened positive for being “at risk for homelessness” and “food insecurity”. Once the patient is stabilized and out of crisis, what resources within your community could you recommend to the patient to address these needs? Who would you reach out to on the interdisciplinary team for further assistance, and why would you reach out to that individual/s?

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