Even as the promotion of health equity is moving front and center for healthcare policy leaders nationwide, a team of healthcare policy researchers is urging policy leaders to think carefully about how patients might be screened for social needs; what’s more, they are urging that some set of mechanisms be put in place to incentivize health systems to help patients with their social needs screening processes.
In their article, published online on Aug. 21 in the JAMA Network and entitled “Inadequacy of Current Screening for Health-Related Social Needs,” they write that, “In 2022, the Centers for Medicare & Medicaid Services (CMS), along with standard-setting organizations such as the National Committee for Quality Assurance (NCQA) and The Joint Commission, established new quality measures aimed at promoting health equity.1-3 Many of these measures center around screening patients for health-related social needs (HRSN). For example, starting in 2024 CMS will require HRSN screening during adult hospitalizations. There is an indisputable connection between social factors (eg, low food security, housing instability), structural racism, poverty, and health. However, without additional considerations, these well-intentioned mandates will impede progress in health equity and have the potential to increase long-standing racial and socioeconomic inequities.”
The article’s authors are Arvin Garg, M.D., M.P.H., Alison LeBlanc, M.S., P.M.P., and Jean L. Raphael, M.D., M.P.H. Garg is founding director of the Child Health Equity Center in Worcester, Mass., and a professor of pediatrics at the UMass Chan Medical School, also in Worcester. LeBlanc is executive director at the Child Health Equity Center. Raphael is an associate professor of pediatrics at the Baylor College of Medicine in Houston.
The article’s authors are keen to make a distinction between two phenomena that they insist are different and should be understood differently. They write that “Policymakers often use the terms social risk and social needs interchangeably with HRSN. Yet, social risks and social needs are different. Social risks are individual-level adverse social factors while social needs are based on an individual’s priorities and perceptions of needs. Screening for social risk vs social needs requires different methods,” they emphasize: “there is little overlap between social risk screening, which relies on validated screening measurement tools, and social need screening, which queries whether a patient desires assistance.”
Further, they write, “Just like any screening tool, social risk screening instruments have inherent fallibilities including false-positives and false-negatives, yet many health systems have designed and implemented their own screening instruments without examining these key issues. Social risk screening may inadvertently emphasize paternalistic care whereby clinicians attempt to address patient risks with motivational interviewing techniques to promote behavioral changes. Our assumption should always be that patients (unless incapacitated) know best what their unmet needs are, eg, if they have enough food for themselves. Given the mistrust and irreparable generational trauma health systems have created among racialized minoritized and/or low-income patients, health care professionals must respect each patient’s decision to seek, or not seek, assistance for social needs.”
The authors point to the pediatrics area as being potentially very useful, noting that back in 2016, the American Academy of Pediatrics was the first organization to recommend HRSN screening at visits, but that inequities have already been found in “the distribution of HRSN screeners and receipt of referrals to social service agencies based on parents’ language and race and ethnicity.” As they note, “low-income minoritized parents often exhibit “feelings of shame, being judged and discriminated against by the health care team, fear that disclosing needs will lead to filings with child protective services and removal of their children, and frustration with disclosing sensitive needs without getting acknowledgment and help. And they point to the “WE CARE” social needs screener, with the acronym standing for “Well-child care visit, Evaluation, Community Resources, Advocacy, Referral, Education,” as a mechanism that can help clinicians, social workers, etc., to sort through some of the issues involved. Above all, they say, “Applying an equity lens to social needs screening, along with determining how HRSN screening is introduced to patients, matters critically and empathy, epistemic trust, respecting parents’ autonomy and dignity, and leveraging existing relationships are core factors necessary for patients to share their social needs willingly and openly. Unfortunately, health systems have paid little attention to these critical factors in implementing HRSN screening. This lapse may have dire unintended consequences.”
The article’s authors recommend that patient care organization leaders “ensure staff administering HRSN screening have ongoing antiracist and cultural humility training”; that leaders “codesign social care support programs with patients, staff, and community members”; and that they “advocate for a robust social safety net.”
In the end, the researchers conclude that “A focus on health equity by CMS and standard-setting organizations is long overdue. Unfortunately, as currently constituted by regulatory organizations, HRSN screening will not fulfill its intended goal of advancing health equity. Screening must be implemented with caution, humility, and empathy, and with an equity lens to understand the needs of marginalized patients and communities. Health systems should support patients, staff, and community members in the design of social care programs that have the potential to promote health equity while also advocating for health-promoting safety net programs. Now is the time for policymakers and health systems to meaningfully invest in holistically addressing health-related social needs for their patients and communities.”
