SIREN Review of Social Screening
[Post Update: On August 1st CMS released their final rule requiring mandatory SDOH screening across 5 domains at time of patient admission for inpatient stay as part of hospital quality measures. In response to concerns about whether the short timeline and lack of resources for implementation would lead to poor quality data, CMS wrote “we note that 92 percent of hospitals already screen for one or more of the five HRSNs—food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety—specified in the proposed measures (87 FR 28498). We believe that this is a strong indication that hospitals have processes in place to conduct the screening required.” In response to concerns over the ethics of screening in SDOH domains for which the health care provider has no available response, CMS responded “We have determined that the proposed voluntary and mandatory reporting periods prioritize the urgency of capturing drivers of health data and taking actionable steps towards closing the health equity gap.”]
Earlier this month, the Vermont Food Access and Health Care consortium published the first installment of the Hunger Vital Sign explainer series. As noted in the series introduction, the Hunger Vital Sign tool for food insecurity risk screening is relevant beyond the food focus - it was an early model for the broader topic of social risk screening in a health care setting.
The Social Interventions Research & Evaluation Network (SIREN) has recently published a report reviewing the catalogue of research on this broader topic: State of the Science on Social Screening in Healthcare Settings (Summer, 2022). This report responds to an issue that is also a theme in our Hunger Vital Sign series. A social risk screen is an important step in a process, but it’s only one step. The goal is to help individuals resolve health related social needs (eg access to healthy food) so that they may experience better health and as part of improving overall community health. This larger goal should ultimately advance health equity. Looking at the body of evidence around step one in the process, what can it tell us about advancing the following steps - resolving resources needs and experiencing better health at both individual and community levels?
The report explores the state of the science through five sections: prevalence of screening; an update on the psychometric and pragmatic validity of existing screening tools; patients’ perspectives on screening; providers’ perspectives on screening; and screening implementation.
Within these sections, we see questions that have also appeared in work in food insecurity screening in Vermont. For example:
What do we mean when we say that social screening has been “implemented” at health care practices? Does screening certain patients for eligibility for a certain program mean implemented? Screening new patients at enrollment, but not at regular intervals? Screening but not entering the results into any structured record? It’s hard to say much about the current screening landscape without getting into fairly detailed questions. See for example this brief review of food insecurity screening in Vermont.
What guidance is available on how to evaluate the quality of the data practices gather from their social screening and to improve this data quality? Experience suggests that it takes both close attention to implementation and repetition / familiarity to make everyone comfortable with having social needs conversations in a health care setting. If screening is used as the first step on an individual patient referral pathway, then even in the earliest stages where responses are most uncertain, there’s still a benefit as individuals receive assistance. However, if low-quality data that under-reports needs or is biased towards a certain patient group gets rolled up into larger conclusions about resource allocation or used in policy making, that is a bigger problem. This problem played into the debate around a recent CMS proposed rule to use social risk screening results as part of hospital quality rating. The question becomes further complicated when translating between two different components of data quality - how consistently the screening itself been implemented (see for example this case study from Accountable Health Communities) and how closely screening results match the social risks / needs that are actually present.
How should health care use individual screening data and broader community level data in complement? Our Hunger Vital Sign explainer discusses this context with Katy Davis of Hunger Free Vermont (see Part 2). We also provide examples of sources of community level health and food systems data in Vermont. In part this question gets at a chicken & egg problem in social risk screening - health care providers don’t want to screen for conditions they can’t offer resources to help resolve, but at the same time the results of screening and referral inform where to prioritize investing in new resources. Community level information can start to answer these questions, with patient screening adding more detailed information and new insights.
Where can health care providers look for guidance on the best screening tools to use? There is neither consensus on what domains to screen for nor on how to best phrase the questions within a given domain. CMMI reviewed over 50 tools and 200 questions for their Health Related Social Needs screening work. A 2019 screening tool comparison chart by SIREN provides one way to organize the different options. The State of the Science report provides an overview of different ways to interpret validity (Section 2, Page 19). For a detailed description of one way to measure validity, see Part 2 & Part 3 our HVS explainer series. Health care practices usually want flexibility for their screening systems. However, flexibility quickly becomes fragmentation. Recent trends have left some practices responding to conflicting screening requirements from payers, grant programs, quality programs, program referrals, research initiatives, and even internally from staff in different departments.
An underlying question is whether some of the proposed policies in social risk screening run ahead of the evidence. That is not (necessarily) a question of whether to advance screening, but more a question of the best tools with which to do so and the amount of focus to put on this one step in isolation from other actions. Bi-State Primary Care Association spoke to this concern in recent comments to CMS.
Ultimately, the SIREN review of evidence reaches the following conclusion:
If you want to be part of helping policymakers learn from experiences with food insecurity screening, be sure to check out the Hunger Vital Sign listening session on July 8th, registration available here.