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Top 3 Challenges to Social Determinants of Health Referrals

Social determinants of health referrals can get beleaguered by limited care coordination and challenges with patient navigation.

For South Texas Physician’s Alliance, social determinants of health referral has been a learning experience.

The organization, which has joined providers across the country in efforts to address social determinants of health, knew the best solution was connecting patients to social services providers.

A patient presenting with food insecurity needs a referral to a food pantry, or a patient with housing insecurity might need the help of a medical-legal partnership.

But even with that strategy, organizations are facing an uphill battle, largely in terms of networking.

“There's just so much that we need to learn because it's just not an area in which medicine is used to functioning,” Sheila Magoon, MD, the executive director of South Texas Physician’s Alliance, told PatientEngagementHIT.

But through an understanding of how to collect SDOH data, the pain points in social services referrals, and the types of technology and interpersonal partnerships the organization would need, South Texas Physician’s Alliance said it’s on the path to building out a strong community health network.

Using provider communication to uncover SDOH

The foremost step to beginning a social determinants of health referral is uncovering the key social determinants of health that patients experience, according to Magoon. But that endeavor is not as simple as it sounds.

Social determinants of health and social needs can be deeply personal to patients, Magoon acknowledged.

Data has shown some patients can be reticent to share social needs because of a patient trust deficit. In 2019, Public Agenda and United Hospital Fund reported that parents understood the link between SDOH and wellness, but did not always share social needs out of fear of judgment or, at worst, being reported to child services.

“That conversation should always be held very delicately and respectfully because social determinant issues can be a very charged thing or can be a source of shame or embarrassment for people,” Magoon explained. “It's really important that to gain that patient trust is really about being genuine, being concerned, taking the time to listen to their needs.”

At South Texas Physician’s Alliance, providers screen for social determinants of health during the annual wellness visit or any time a patient brings up a social need. This approach is essential because it embeds time for SDOH communication directly into the clinical encounter, a big leg-up for clinicians who often find themselves strapped for time.

South Texas Physician’s Alliance equips nurses and highly trained medical assistants with paper SDOH screeners to determine specific patient needs. From there, the medical personnel integrate patient responses into the EHR so providers can better understand the social circumstances that shape patient health. Again, this team-based approach is helpful for over-burdened physicians.

It is also effective because it puts the patient at ease, Magoon added.

“That has worked well because then patients are less apprehensive. They share more,” she stated. “And because we use a tool that helps us structure our staff to be able to get those to have that conversation, that very sensitive conversation with the patients to be able to find out more about what their needs are and so that they don't feel embarrassed or apprehensive.”

Identifying social services referrals

For many healthcare organizations, this process has entailed flipping through a phone book and asking colleagues for references. Who knows a good medical transportation company? Who can help this patient with jobs training?

When South Texas Physician’s Alliance set its sights on social determinants of health work, it found it was hard to pinpoint a resource for a patient after she’d disclosed a social need. Without a solution to a problem, it’s hard for a clinician to actually have SDOH conversations with patients, and in some cases patient trust can suffer.

“The biggest challenge is finding the appropriate service agency or resource within our community to assist our patients,” Sheila Magoon, MD, the executive director of the South Texas Physician’s Alliance, said in an interview. “And also, if we find them, then do they even have the capacity or the funding to be able to add more clients or the personnel or their internal personnel bandwidth to add those patients in?”

Patient navigation, social services coordination

What’s more, Magoon and her team have encountered issues with patient navigation and social services. Care coordination can be difficult for even the most seasoned of doctors, but asking a patient to be an arbiter of her social- and health-related care can be arduous.

“The other challenge is really about health literacy and the capacity of the patients to navigate those services on their own,” Magoon explained. “You get the clients, you get them connected to the service agency, then they still have an application process that they have to go through and they have to provide proof of income and those kinds of things, or what their housing arrangements are.”

And that’s a tall order for patients who have already clearly expressed a social need. There are multigenerational households to consider, people who have temporary living situations who may find that their circumstances are in fact disqualifying criteria. It isn’t always fair to ask a patient to disclose her social needs and then push her toward a complex web of social services applications requirements, Magoon suggested.

Using SDOH referral systems

South Texas Physician’s Alliance has tapped SDOH referral technology from LeadingReach, an effort Magoon said helped streamline the organization’s care coordination efforts and connect patients to care.

The tool lets providers scan for specific social services that can help fill a reported SDOH. From there, the provider can send off a referral, check whether the patient indeed accessed the social service, and track the process from start to finish.

The system hinges on strong community health partnerships, Magoon added. When piloting the system after utilizing it for more traditional care coordination strategies, Magoon said her team quickly saw its potential for closing gaps in social services referrals.

“We thought, you know what? We wonder if that would help our social determinant side, our referrals to social, some of the local agencies,” Magoon posited.

“We talked to one of the agencies that we've been working with for several years, but it's all been by phone and fax. And while it works, there's just a lot of frustration for us. We said, ‘Hey, would you be willing to pilot this with us?’”

South Texas Physician’s Alliance’s partners said yes, helping to build out a strong social services referral system.

And moving forward, Magoon expects that network to continue to grow.

The organization will investigate which social determinants of health are most common to its patient populations. This will begin with anecdata, Magoon noted, but as the system gets use it should generate more data-driven insights to help the organization identify the types of community partners it needs.

“At this point, it's going to be more just a matter of what our care coordinators have identified and just going off of those,” Magoon concluded. “We know that over time, we'll be able to have an ability to start tracking what some of those needs are. So that way we can better address those issues and find out if those service providers are available. And if not, can we approach some of the nonprofits in our region and say, ‘Hey, would you like to take on a new project?’”

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