Measuring Social Needs and Outcomes: Key Considerations

How can health care organizations measure patients’ social needs in a way that allows the data to be actionable? This is a question that many communities are grappling with as they strive towards “whole person care models” that consider a range of needs beyond health care—from housing to food insecurity to intimate partner violence and beyond.

A growing recognition of the importance of social determinants of health (SDOH) has led to a proliferation of screening and assessment tools, but there are currently no national standards for how to systematically capture and address the non-health needs of patients. To provide some guidance for communities just starting out on this path, All In: Data for Community Health hosted a webinar featuring two subject matter experts.

Dr. Caroline Fichtenberg of the Social Interventions Research and Evaluation Network (SIREN) reviewed the current landscape of screening tools and outcome measures, while Karis Grounds of 2-1-1 San Diego demonstrated the methodology and framework of their risk rating scale, which is helping them better serve their clients while showing the impact of service referral and utilization over time. Presenters highlighted the following questions to consider when developing a strategy for measuring social needs.

1. Are there existing screening tools that match your community’s specific context?

A number of screening tools have been developed to identify patient’s social needs in health care settings, and choosing the right tool requires investigation into which domains are most applicable to your population and can easily be incorporated into your organization’s workflow. Dr. Fichtenberg explained:

“There’s a lack of standardization for these questions and how to do this, which means there’s a lot of room for customization, and that is good but it’s also hard for people who want an off-the shelf tool. The advantage is that you have options in terms of different domains and depending on your population, some of these issues may be more important than others.”

The good news is that SIREN has already researched the most widely used screening tools and put together a side-by-side comparison table, including information on the intended population or setting, domains/topics covered, and the number of questions dedicated to each domain.

2. What aggregate data on social needs are already available?

Dr. Fichtenberg recommended reviewing existing public health data on social needs, such as population-level census data, Behavioral Risk Factor Surveillance System (BRFSS) data and other types of readily available health data, to examine prevalent health issues and services that are needed in specific neighborhoods. This data can help communities determine which social needs domains are most relevant for their population when developing a new screening program.

Although aggregate measures are not helpful in understanding individual needs, they’re potentially much easier to systematically collect and can help identify “hot spots” in a community where interventions should be targeted, especially if it’s not feasible to conduct a widespread screening program.

3. What further assessment is needed for someone who screens positive?

Social factors impacting health outcomes can be complex, so it’s worth considering how they may be interrelated. For example, someone who is food insecure may face other economic challenges, like housing or job instability, issues that could be addressed simultaneously.

Grounds emphasized that if a patient screens positive for a particular need in a health care setting, an in-depth follow-up assessment from the appropriate social service provider is needed to get a more nuanced understanding of their barriers and the most effective approach to address the situation. She explained:

“We don’t necessarily just ask if you’re positive for food insecurity. We might ask additional questions like: ‘Do you need food now or in a week? Do you have transportation? What barriers to you have to getting food?’ Looking at more of the interconnection of all those needs and really understanding it more as an assessment.”

4. What interventions are most effective for addressing social needs?

To make the greatest impact in addressing social needs, screening programs should take a holistic approach, connecting patients with community resources that are the best fit based on their specific situation.

For example, 2-1-1 San Diego’s risk rating scale identifies the nature and severity of a client’s needs across 14 social determinants of health. The risk rating scale takes into account the immediacy of the client’s need, their knowledge and utilization of resources, and limitations or barriers to accessing support. Using this information, they can identify where clients fall on a continuum from “crisis” to “thriving,” create a personalized care plan that connects them with resources that will most likely improve their situation, and track change over time.

5. How should impact be measured?

Dr. Fichtenberg described the results of a systematic review conducted by SIREN comparing social determinants of health interventions, which found that more research focuses on process outcomes, like whether patients are screened and referrals are made, in comparison to health, cost, and utilization outcomes, which are much harder to measure but help to build the evidence base about the effectiveness of social needs screening programs.

Grounds shared the outcomes from a recent social needs screening pilot project 2-1-1 San Diego conducted with a local hospital, which resulted in a 20% reduction in hospital readmissions. She stressed that more research on health outcomes is essential to demonstrate the value of these programs, stating:

“When you have poor BMI or high blood pressure, there is a risk, a tool, a number associated with how doctors can communicate that information. When we start working with social service providers, we really don’t have a lot of standards and practices. We need to show the measures to be able to say we’re making improvements, our work is valuable, and there is an ROI for health outcomes from the connections we’re making to community-based resources.”

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