With the shift to value-based healthcare reimbursements, social determinants of health (SDOH) are taking a more prominent role in how patients are being assessed at home. This puts community health workers and other providers in the field at the forefront of identifying patient risk factors and addressing their needs in a way that reduces critical health disparities.

As with any new practice or procedure, adding another screening can be a bit intimidating at first.

Addressing SDOH Is Beyond the Reach of Field Assessments

SDOH gets mentioned a lot, but what exactly are they? SDOHs are societal factors that affect everyone. It’s estimated that as much as 80% of health outcomes are impacted by SDOH. In and of themselves, SDOH is neither positive nor negative. But their presence or absence can lead to positive or negative health outcomes.

Assessing Patients in the Field for Social Risk Factors

Generally, SDOHs are sorted into five overarching categories:

  • Economic stability
  • Education access and quality
  • Healthcare access and quality
  • Neighborhood and built environment
  • Social and community context

Since the SDoHs are overarching, it’s difficult to see how any single patient assessment in the field can have an impact on them. Community health workers, paramedics, and other healthcare providers are often left asking themselves “What can I do to improve this patient’s economic stability or neighborhood?” The obvious answer is not much.

However, when we shift the focus to assessing the patient’s social risk factors and immediate social needs, the impact a responder in the field can have becomes much clear. SDOH risk scores and clusters of social risk matters can help to indicate the range of social needs that we need to account for patients as we work to improve health equity and population health. This can be achieved by implementing and scaling effective tools for assessing and addressing SDoH.

Assessing Social Risk Factors and Immediate Needs in the Field Can Be Effective

By focusing on the patient’s immediate needs using social risk factors during the assessment in the field, the responder can address tangible aspects of the patient’s situation. The data gathered can be used to improve patient care and reduce barriers.

By looking at SDOH risk scores, care utilization patterns can be uncovered, pointing out gaps in care. Using SDOH risk scores to identify issues with medication adherence and other unmet needs can help identify the best community resources to call on. These interventions can reduce barriers to care and prevent disease progression.

Z-codes are ICD-10-CM diagnosis codes used to document and map SDOH data. They are standardized, providing a commonly understood and accepted basis for recording and analyzing the individual patient’s social risk factors and unmet needs. They can also inform the patient’s care plan and follow on care.

Assessing for social risk factors asks whether the patient is currently experiencing any of the following:

  • Housing instability
  • Food insecurity
  • Difficulty accessing utilities (e.g., electrical power, water, phone service, internet access)
  • Difficulty with meeting transportation needs
  • Personal safety at risk

Since these needs are tangible, immediate, and specific they can be more effectively assessed and addressed. Referrals to agencies and programs can be made. Follow-up services, like arranging transportation to a doctor's appointment, can be scheduled.

Addressing the patient’s immediate needs (physical, mental, and social) improves the likelihood that the patient will experience better outcomes.

How to Screen for Social Risk Factors and Immediate Needs in the Field

With a focus on social risk factors and immediate needs, community health workers, paramedics, and other healthcare providers can ask questions that screen for specific gaps the patient is experiencing.

Several screening tools that include the types of questions to ask are available, including one from CMS. And efforts have been made to review and improve screening questions as in this 2020 article from the Western Journal of Emergency Medicine.

Here are a few examples of screening questions that are commonly asked:

Regarding access to food:
  • In the past 12 months, have you worried that your food would run out before you got money to buy more?
  • In the past 12 months, has your food run out and you didn’t have money to get more?
  • Would you like resources to help with obtaining food?
Regarding utilities:
  • In the past 12 months, have you worried that any utility (electric, gas, water, or oil) would be shut off for not paying your bills?
  • Would you like resources to help with paying your utility bills?
Regarding safety:
  • How often does anyone, including family and friends, physically hurt you?
  • Would you like resources to help you stay safe?

Keeping the screening questions focused on tangible needs points to the specific kinds of resources that will be most helpful to the patient.

Some patients might find it difficult to disclose or discuss some of their immediate needs. This seems to be particularly the case when it comes to personal safety. Using commonly used language and not medical or healthcare jargon (asking about running out of food, instead of food insecurity) makes it easier for the patient to be candid and frank in their responses.

Respond at Once to Address Immediate Needs

Once a patient’s social risk factors and immediate needs have been identified, it’s best to address them immediately. This can mean making a referral to an agency or program. Or it can be checking with a shelter for available space.

Being able to make these referrals quickly and effectively reduces the likelihood that the patient’s care will be disrupted by a missed appointment or having to wait for support services to be delivered.

Capturing all the patient’s information (assessments, treatments, referrals, etc.) in a platform easily shared by all the patient’s healthcare and social welfare providers strengthens the patient’s overall care plan. Information can flow freely among the providers and agencies allowing them to see the complete course of care, including the steps that have been completed and those that remain to be done.

In the end, immediate response and better care coordination lead to better health outcomes for the patient and reduces the probability of relapse or readmission.

MIH-CP Programs are extending healthcare services by incorporating pharmacists-led medication management delivery solutions

With Rainbow Health Effectively Assess Social Risk Factors in the Field

Being able to effectively assess the patient’s social risk factors and immediate needs in the field leads to better health outcomes and supports value-based care. This allows for a more holistic approach that optimizes each patient’s care delivery in a way that brings into focus preventative care and chronic conditions management.

Several features of our platform enable these assessments and the follow-up care patients need. From easily integrating your screening tools and enabling quick messaging to partners, Rainbow Health helps keep your workflow smooth. Our mobile app and easy access to educational content make it effortless for patients to stay engaged with their care plan and get the right aid for social and other impacted needs.

Implement easy access to keep your patients engaged with our integrated Rainbow Health services

Author's Bio

Ayushi Patel Mobisoft Infotech

Ayushi Patel

Ayushi Patel is the Director of Strategy & Innovation at Mobisoft Infotech. She leads the strategic partnerships and initiatives in the healthcare division. Her experience includes healthcare administration, business development and sales, and customer success management.