Development, Implementation, and Formative Evaluation of a Social Needs Screening Tool.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

BACKGROUND Social needs and social determinants of health (SDOH) significantly outrank medical care when considering the impact on a person’s length and quality of life, resulting in poor health outcomes and worsening life expectancy. Integrating social needs and SDOH data along with clinical risk information within operational clinical decision support (CDS) systems built into electronic health records (EHRs) is an effective approach to addressing health-related social needs. To achieve this goal, applied research is needed to develop EHR-integrated CDS tools and closed-loop referral systems and implement and test them in the digital and clinical workflows at health care systems and collaborating community-based organizations (CBOs). OBJECTIVE This study aims to describe the protocol for a mixed methods study including a randomized controlled trial and a qualitative phase assessing the feasibility, acceptability, and effectiveness of an EHR-integrated digital platform to identify patients with social needs and provide navigation services and closed-loop referrals to CBOs to address their social needs. METHODS The randomized controlled trial will enroll and randomize adult patients living in socioeconomically challenged neighborhoods in Baltimore City receiving care at a single academic health care institution in the 3-month intervention (using the digital platform) or the 3-month control (standard-of-care assessment and addressing of social needs) arms (n=295 per arm). To evaluate the feasibility and acceptability of the digital platform and its impact on the clinical and digital workflow and patient care, we will conduct focus groups with the care teams in the health care system (eg, clinical providers, social workers, and care managers) and collaborating CBOs. The outcomes will be the acceptability, feasibility, and effectiveness of the CDS tool and closed-loop referral system. RESULTS This clinical trial opened to enrollment in June 2023 and will be completed in March 2025. Initial results are expected to be published in spring 2025. We will report feasibility outcome measures as weekly use rates of the digital platform. The acceptability outcome measure will be the provider’s and patient’s responses to the truthfulness of a statement indicating a willingness to use the platform in the future. Effectiveness will be measured by tracking a 3-month change in identified social needs and provided navigation services as well as clinical outcomes such as hospitalization and emergency department visits. CONCLUSIONS The results of this investigation are expected to contribute to our understanding of the use of digital interventions and the implementation of such interventions in digital and clinical workflows to enhance the health care system and CBO ability related to social needs assessment and intervention. These results may inform the construction of a future multi-institutional trial designed to test the effectiveness of this intervention across different health care systems and care settings. CLINICALTRIAL ClinicalTrials.gov NCT05574699; https://clinicaltrials.gov/study/NCT05574699 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/57316

BackgroundSocial needs and social determinants of health (SDOH) significantly outrank medical care when considering the impact on a person’s length and quality of life, resulting in poor health outcomes and worsening life expectancy. Integrating social needs and SDOH data along with clinical risk information within operational clinical decision support (CDS) systems built into electronic health records (EHRs) is an effective approach to addressing health-related social needs. To achieve this goal, applied research is needed to develop EHR-integrated CDS tools and closed-loop referral systems and implement and test them in the digital and clinical workflows at health care systems and collaborating community-based organizations (CBOs).ObjectiveThis study aims to describe the protocol for a mixed methods study including a randomized controlled trial and a qualitative phase assessing the feasibility, acceptability, and effectiveness of an EHR-integrated digital platform to identify patients with social needs and provide navigation services and closed-loop referrals to CBOs to address their social needs.MethodsThe randomized controlled trial will enroll and randomize adult patients living in socioeconomically challenged neighborhoods in Baltimore City receiving care at a single academic health care institution in the 3-month intervention (using the digital platform) or the 3-month control (standard-of-care assessment and addressing of social needs) arms (n=295 per arm). To evaluate the feasibility and acceptability of the digital platform and its impact on the clinical and digital workflow and patient care, we will conduct focus groups with the care teams in the health care system (eg, clinical providers, social workers, and care managers) and collaborating CBOs. The outcomes will be the acceptability, feasibility, and effectiveness of the CDS tool and closed-loop referral system.ResultsThis clinical trial opened to enrollment in June 2023 and will be completed in March 2025. Initial results are expected to be published in spring 2025. We will report feasibility outcome measures as weekly use rates of the digital platform. The acceptability outcome measure will be the provider’s and patient’s responses to the truthfulness of a statement indicating a willingness to use the platform in the future. Effectiveness will be measured by tracking a 3-month change in identified social needs and provided navigation services as well as clinical outcomes such as hospitalization and emergency department visits.ConclusionsThe results of this investigation are expected to contribute to our understanding of the use of digital interventions and the implementation of such interventions in digital and clinical workflows to enhance the health care system and CBO ability related to social needs assessment and intervention. These results may inform the construction of a future multi-institutional trial designed to test the effectiveness of this intervention across different health care systems and care settings.Trial RegistrationClinicalTrials.gov NCT05574699; https://clinicaltrials.gov/study/NCT05574699International Registered Report Identifier (IRRID)DERR1-10.2196/57316

To identify implementation strategies that effectively facilitate the adoption of social needs care coordination activities using enabling technologies among care management teams serving patients in community-based health centres. Modified Delphi process. Discrete, feasible implementation strategies were identified through literature review and semi-structured interviews with care management staff and subject matter experts in clinical informatics, workflow redesign, and product engineering. A modified Delphi was conducted with eight subject matter experts and nine health centre care management staff. Iterative rounds of online surveys were used to achieve consensus on the most relevant implementation strategies and their delivery methods. The modified Delphi process achieved consensus on nine discrete implementation strategies needed to advance care management teams' ability to screen, refer and track social needs. Prioritised strategies included developing champions, enhancing quality improvement capacity, training staff on using enabling technologies and providing tailored technical assistance for workflow refinement. Consensus was also reached on a monthly cadence for most of the implementation strategies. Consensus was reached on strategies to enhance care management teams' implementation of social needs screening, referrals and tracking using enabling technologies. These strategies will comprise an intervention to be pilot tested, refined and assessed in a cluster randomised clinical trial. Findings from this study will inform the development of strategies to further the adoption of enabling technologies to support social needs care coordination. This work is key to the design of a type 2 hybrid implementation-effectiveness trial that will assess whether user-informed, evidence-based implementation strategies can improve care management teams' adoption of enabling technologies to facilitate social needs care coordination for patients. The research team includes a patient advisor with community-based nursing expertise and a nurse practitioner-clinical informaticist leader who was involved in data collection and interpretation of findings. Clinicaltrials.gov registration # NCT06489002. Registered July 5, 2024, https://clinicaltrials.gov/study/NCT06489002?term=NCT06489002&rank=1.

Ten years ago, when I left my position as an assistant commissioner at the Massachusetts Department of Public Health, very few state—or local or federal—health departments mounted health initiatives targeted at lesbian, gay, bisexual, or transgender (LGBT) populations. The only exception involved HIV/AIDS, which the large numbers of HIV-positive gay and bisexual men made virtually (although not always) impossible to ignore. Over the past decade, several city health departments, including the one I led as commissioner of health for Boston, have created staff positions or offices to address the health of the LGBT community. Yet, when I returned to the Massachusetts Department of Public Health a year ago, I found that there had been little progress at the state level in addressing either the diverse health needs of LGBT populations or the complex ways in which discrimination negatively affects health—even though, in the interim, there had been important and groundbreaking efforts, such as the founding of the National Coalition of LGBT Health and the publication of the Healthy People 2010 Companion Document for LGBT Health. In addition, of course, the LGBT community made significant progress in other arenas, including the historic legalization of gay marriage in Massachusetts, where the marriage licenses of gay couples are proudly filed alongside those of heterosexual couples. Outstanding researchers like the ones whose works are highlighted in this edition of the Journal are admirably addressing a range of public health issues that affect the LGBT community, including smoking, violence, chronic disease, tuberculosis, and access to care. The emphasis of much of the published work, however, continues to be on HIV and sexually transmitted diseases. While this work is essential, so is the need to increase the range of the subject matter. The current, overly narrow focus on HIV and sexually transmitted diseases within the LGBT community reflects the continuing existence of homophobia and transphobia, but it also results from the rarity with which data on sexual orientation and gender identity are collected in public health or clinical settings. The vast majority of our survey instruments do not inquire about these characteristics (to be fair, neither do they ask about economic class or ethnicity). This leaves anecdotal observation or limited-size studies as the only evidence of which health conditions and risks disproportionately affect LGBT populations. We can observe the impact of this barrier in this special issue of the Journal, the content of which makes it clear that some of the finest researchers in the country have an easier time getting funding for their work when they focus on sexually related conditions. This is unfortunate. It brings to mind other stereotyping of specific populations (e.g., categorizing women’s needs as being mainly about reproductive health, and assuming that adolescent needs are mainly about drugs and sex). Both the public and the private sectors need to address this deficiency. We can learn from the recent successful efforts of numerous cities and states to implement major initiatives to combat racial and ethnic health disparities, which have included improved collection and analysis of data. Without a greater foundation for routinely obtaining accurate population-based data, though, researchers will continue looking at the same incomplete picture. In addition, the public health community will lack the information it needs to understand and address the health issues of LGBT communities. The Journal’s necessary attention to LGBT health will advance this effort—not only by showcasing superb researchers who help us gain useful insights, but also by reminding us of the important work yet to be done.

Background: The dating style of today's adolescents shows risky behavior that is not appropriate for their age, such as behavior that leads to premarital sex. The process of sexual interaction in adolescents is described in five phases which include touching, courtship without kissing, kissing, touching sensitive body parts (such as breasts and genitals), and sexual intercourse. Basic social needs are a very important variable in motivating behavior. Purpose: To determine the relationship between fulfilling social needs and risky dating behavior in adolescents. Method: The study used a quantitative descriptive method with a total sampling of 107 respondents. The measuring instrument in this study used a social needs questionnaire and a premarital sexual behavior questionnaire. This study uses a descriptive statistical analysis test and the correlational coefficient Spearman's rho (Sig = <0.05). Results: On average, adolescent’s social needs are met at 69.2% and adolescents dating behavior is at a low risk level at 69.2%. This research shows that there is a significant relationship between the two variables with a significance value of 0.001 (<0.05) and a correlation coefficient of -0.323, meaning that the level of strength of the relationship between the two variables reflects a fairly strong relationship in a negative direction (not in the same direction), which means that if If the value of fulfilling social needs decreases, the value of risky dating behavior will increase. Conclusion: There is a fairly strong negative relationship between fulfilling social needs and risky dating behavior in adolescents. Suggestion: Collaboration between nursing students, schools, parents, health workers and the community to conduct research or sexual health education programs that focus on building healthy interpersonal relationships and managing the risks of premarital sexual behavior in adolescents is important to prevent the emergence of disease from risky dating behavior. Keywords: Adolescents; Risky Dating Behavior; Social Needs. Pendahuluan: Gaya berpacaran pada remaja saat ini menunjukan perilaku berisiko yang tidak sesuai dengan usianya seperti perilaku yang mengarah kepada hubungan seks pra-nikah. Proses interaksi seksual pada remaja diuraikan menjadi lima fase yang meliputi, menyentuh, berpacaran tanpa kegiatan berciuman, melakukan ciuman, melakukan sentuhan pada bagian tubuh sensitif (seperti payudara hingga kelamin), dan berhubungan intim seksual. Kebutuhan dasar social needs merupakan variabel yang sangat penting dalam memotivasi perilaku. Tujuan: Untuk mengetahui hubungan antara pemenuhan social needs dengan perilaku pacaran berisiko pada remaja. Metode: Penelitian menggunakan metode deskriptif kuantitatif dengan total sampling sebanyak 107 responden. Alat ukur dalam penelitian ini menggunakan kuesioner social needs dan kuesioner perilaku seksual pra-nikah. Penelitian ini menggunakan uji analisis statistic deskriptif dan Correlational Coefficient Spearman’s rho (Sig = <0.05). Hasil: Rata-rata kebutuhan social needs remaja cukup terpenuhi sebanyak 69.2% dan perilaku pacaran remaja rata-rata pada tingkat risiko rendah sebanyak 69.2%. Penelitian ini menunjukan terdapat hubungan yang signifikan antara kedua variabel dengan nilai signifikansi sebesar 0.001 (<0.05) dan koefisien korelasi -0.323, berarti tingkat kekuatan keterkaitan antara kedua variabel tersebut mencerminkan relasi yang cukup kuat dengan arah hubungan negatif (tidak searah) yang artinya, jika nilai pemenuhan social needs menurun maka nilai perilaku pacaran berisiko akan semakin meningkat. Simpulan: Terdapat hubungan negatif yang cukup kuat antara pemenuhan social needs dengan perilaku pacaran berisiko pada remaja. Saran: Kerjasama antara mahasiswa keperawatan, sekolah, orang tua, tenaga kesehatan, dan masyarakat untuk melakukan penelitian atau program pendidikan kesehatan seksual yang berfokus pada pembangunan hubungan interpersonal yang sehat dan pengelolaan risiko perilaku seksual pra-nikah pada remaja penting untuk mencegah timbulnya perilaku pacaran berisiko. Kata Kunci: Remaja; Perilaku Pacaran Berisiko; Social Needs.

Health-related social needs (HRSN) influence health outcomes and health care utilization. Clinicians face challenges addressing HRSN due to limited skills, expertise, and time. Further insight is needed on how patients and clinicians navigate HRSN in clinical encounters. This study examines outpatient primary care encounters predating widespread HRSN screening to identify how discussions on HRSN are initiated and addressed. This qualitative analysis was conducted on transcripts of 97 audiotaped English-speaking patient encounters from 3 clinics in New York City within a municipal health care system from January 2011 through April 2015. Patients were eligible if they were older than 18 years, self-identified as Black or White, had a diagnosis of hypertension, and had at least one prior encounter with the participating clinician. Codes were developed from social needs domains addressed by the Accountable Health Communities HRSN Screening Tool. Codes were added for further social needs identified, whether a patient or clinician initiated the HRSN discussion, and how a social need was addressed, if at all. Encounters were analyzed between June 2023 and February 2024. Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics. A total of 97 patients (55 [56.7%] women, 58 [59.8%] Black, mean [SD] age, 59.7 [10.6] years) had audiotaped encounters with 27 clinicians (18 [66.7%] women, 15 [55.6%] White, mean [SD] age, 36 [5.8] years). Physical activity (36% of encounters), financial strain (35%), mental health (34%), and substance use (28%) were the most discussed HRSN domains across the 97 encounters. Patients introduced financial strain most often (70% of the time), while clinicians led substance use (75%), physical activity (51%) and mental health (51%) discussions. Patients initiated conversations on employment (77%), food insecurity (62%), and housing instability (52%). Interventions included prescriptions, forms, counseling, and referrals. Domains frequently intervened on included health care navigation needs (85% of discussions), substance use (33%), and mental health (27%). In this qualitative study of HRSN discussions in primary care encounters, clinicians were more likely to initiate discussions on substance use, physical activity, and mental health, behaviors routinely assessed in primary care, but different from topics introduced by patients. Findings underscore the need for standardized screening to improve identification of domains less frequently addressed by clinicians. Additional interventions are also needed, including clinician training for how to address HRSN in resource-constrained settings and integration of other health care team members, to enhance HRSN identification and intervention.

Health-related socioeconomic risk screening in outpatient obstetrics and gynecology practice

Social determinants have an outsized impact on health outcomes. Given the increasing awareness of this impact and the adoption of alternative payment models that incentivize addressing social needs, expectations are growing that health systems will appropriately screen for patients' social needs. However, there is limited evidence on how patients would like their health systems to engage with them around these needs. Our objective was to understand patient perspectives on completing social needs screening through technology-based modalities. We performed a qualitative study with semistructured patient interviews from November 2021 to April 2022. Patients were eligible for our health system's standardized social needs screening survey if they had not completed it in the past year and were scheduled for a nonacute primary care visit. Patients were selected for interview if they completed the survey via portal or tablet or if they were eligible for but did not complete the survey. Interviews were analyzed using an integrated approach. Domains, subdomains, and themes were identified. We completed interviews with 54 participants. Participants were broadly accepting of screening, and most were comfortable with portal or tablet-based screening. They were motivated to complete the screening and recognized the connection between social needs and health. Having a trusting relationship with their clinician and feeling that their information was private were noted by patients as important factors for process endorsement. This qualitative study provides insight into patient-centered approaches for identifying patients' social needs.

BackgroundHealth care providers are increasingly screening patients for unmet social needs (eg, food, housing, transportation, and social isolation) and referring patients to relevant community-based resources and social services. Patients’ connection to referred services is often low, however, suggesting the need for additional support to facilitate engagement with resources. SMS text messaging presents an opportunity to address barriers related to contacting resources in an accessible, scalable, and low-cost manner.ObjectiveIn this multi-methods pilot study, we aim to develop an automated SMS text message–based intervention to promote patient connection to referred social needs resources within 2 weeks of the initial referral and to evaluate its feasibility and patient acceptability. This protocol describes the intervention, conceptual underpinnings, study design, and evaluation plan to provide a detailed illustration of how SMS technology can complement current social needs screening and referral practice patterns without disrupting care.MethodsFor this pilot prospective cohort study, this SMS text message–based intervention augments an existing social needs screening, referral, and navigation program at a federally qualified health center. Patients who received at least one referral for any identified unmet social need are sent 2 rounds of SMS messages over 2 weeks. The first round consists of 5-10 messages that deliver descriptions of and contact information for the referred resources. The second round consists of 2 messages that offer a brief reminder to contact the resources. Participants will evaluate the intervention via a survey and a semistructured interview, informed by an adapted technology acceptance model. Rapid qualitative and thematic analysis will be used to extract themes from the responses. Primary outcomes are implementation feasibility and patient acceptability. Secondary outcomes relate to intervention effectiveness: self-reported attempt to connect and successful connection to referred resources 2 weeks after the initial referral encounter.ResultsThe study received regulatory approval in May 2021, and we anticipate enrolling 15-20 participants for this initial pilot.ConclusionsThis protocol presents detailed implementation methods about a novel automated SMS intervention for social care integration within primary care. By sharing the study protocol early, we intend to facilitate the development and adoption of similar tools across different clinical settings, as more health care providers seek to address the unmet social needs of patients. Study findings will provide practical insights into the design and implementation of SMS text message–based interventions to improve social and medical care coordination.International Registered Report Identifier (IRRID)DERR1-10.2196/37316

Introduction: Consistent evidence has shown that the social determinants of health (SDoH) play an important role in shaping overall health. As health systems become more focused on improving the health of populations, there is an urgent need for interventions that address upstream factors such as the social determinants of health. Such interventions have not been widely studied and even less work exists in the realm of maternal health. But as maternal and infant mortality remain critical issues, there is great opportunity for the study and development of interventions to address social needs in pregnancy care. Hypothesis: We assessed the hypothesis that most existing interventions addressing the social needs of pregnant women would focus only on identifying social risks, while fewer would connect patients with resources in the community. We expected that most studies would not provide evaluations of effectiveness. Methods: We conducted a database search of MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science to capture literature published between January 1970 and April 2019. A team of reviewers screened titles and abstracts for interventions that were issued in a clinical setting and addressed at least one SDoH as defined by the World Health Organization. Results: Preliminary results revealed 25 studies. All consisted of some form of risk screening and four included a referral process. Interventions addressing intimate partner violence were most numerous followed by psychosocial factors and cigarette smoking. Financial needs were assessed in one study. Eight studies included an evaluation process. Staff carrying out the interventions were primarily research staff, nurse practitioners or nurse midwives. Conclusions: In conclusion, more must be done to connect pregnant women with social resources. As unmet social needs put women at higher risk for poor outcomes in pregnancy, action should be taken to more seamlessly integrate social needs interventions into clinical workflows. Focus should expand beyond traditional social risk screening to capture a wider range of needs including financial stability, housing, and transportation. These are particularly important during pregnancy because adequate prenatal care requires women to be more engaged with the health care system than they would to maintain baseline health.

Unmet social needs (e.g., housing instability, food insecurity, transportation barriers) impact a patient’s ability to participate in health-seeking behaviors (e.g., physical activity, routine preventive care) and to achieve optimal health. A rapidly growing number of health care systems are incorporating social needs screening and assistance into clinical workflows, yet many implementation and sustainability challenges exist and require collaboration with social service organizations. This review highlights implementation approaches used within this rapidly changing US landscape and uses implementation science frameworks to systematically identify multilevel barriers to and facilitators of implementing and sustaining social needs care. Policies and economic investments are necessary as they determine critical barriers and facilitators within the clinical and social service contexts. Implementation may be further strengthened by cross-sector engagement, evidence-based implementation strategies, and capacity building within clinical and social service organizations. Successful, sustained implementation of social needs care may improve the quality of health care, population health, and health equity.

Screening for social needs is recommended during clinical encounters but multi-item questionnaires can be burdensome. We evaluate if a single question about financial stress can be used to prescreen for food insecurity, housing instability, or transportation needs. We use retrospective medical record data from children (<11 years) seen at 45 primary pediatric care offices in 2022. Social needs screening was automated at well child visits and could be completed by the parent/guardian via the patient portal, tablet in the waiting room, or verbally with staff. We report the area under the receiver operating curve for the 5 response options of the financial stress question as well as sensitivity and specificity of the financial stress question ("not hard at all" vs any other response) to detect other reported social needs. Of 137 261 eligible children, 130 414 (95.0%) had social needs data collected. Seventeen percent of respondents reported a housing, food, or transportation need. The sensitivity of the financial stress question was 0.788 for any one or more of the 3 other needs, 0.763 for food insecurity, 0.743 for housing instability, and 0.712 for transportation needs. Using the financial stress question as the first-step of a screening process would miss 9.7% of the families who reported food insecurity, 22.6% who reported housing instability, and 33.0% who reported transportation needs. A single question screener about financial stress does not function well as a prescreen because of low sensitivity to reports of food insecurity, housing instability, and transportation needs.

Nonoccupational HIV postexposure prophylaxis (NPEP) protocols and barriers to NPEP utilization in massachusetts emergency departments

Social determinants of health have been demonstrated to be important drivers of health outcomes and disparities. Screening for social needs has been routinely performed and shown to be beneficial in ambulatory settings, but little is known regarding parent perspectives on screening during pediatric hospitalizations. This study sought to determine parental attitudes surrounding inpatient screening and screening process preferences in the hospital setting. We conducted 17 semistructured interviews with English- and Spanish-speaking parents of hospitalized children at 1 tertiary and 2 community hospitals between July 2020 and February 2021, with questions probing opinions and experiences with social needs screening, comfort level with discussing social needs with hospital providers, and screening process preferences in the hospital setting. Interviews were recorded, professionally transcribed, and analyzed thematically. Participants were median age 32 years, with majority female and English-speaking, and nearly one-half with children admitted to a community hospital. Emergent themes included (1) importance of screening for social needs across multiple health care settings, (2) hospitals viewed as capable systems to respond to social needs, (3) most parents comfortable discussing social needs with inpatient providers, (4) appreciation for providers expressing caring and desire to help during inpatient screening, and (5) importance of a family-centered approach to inpatient screening. Parents reported positive perceptions regarding pediatric inpatient social needs screening importance and hospitals' ability to address social needs and identified multiple screening process preferences for the hospital setting that can inform the development of family-centered inpatient social needs screening strategies.