Roebuck E, Urquieta de Hernandez B, Wheeler M et al: Lessons learned: social determinants of health screening pilot in 2 urology clinics. Urol Pract 2021; 9: 87.

Background

Recognizing how social factors largely impact patient and population health, social determinants of health (SDOH) was the term coined to describe those conditions under which people are born, live, grow, work and play (fig. 1). Studies have shown that unmet social needs contribute to poorer health outcomes, increased emergency department utilization and deepened health inequities.^1–3 The American College of Physicians has recommended research, screening and treatment around SDOH to improve patient care and promote health equity.⁴ Already, primary care providers have sought to better acknowledge and address unmet social needs through SDOH screening and referral under various models. Yet despite studies highlighting the relevance of SDOH across fields, little movement has been made thus far in addressing social needs within surgical subspecialties.^5,6

Figure 1. Factors influencing overall health. Figure used by permission of the Institute for Clinical Systems Improvement.

Having the only urology clinic in a diverse, predominantly urban county targeted specifically to serve uninsured/underinsured patients, we were compelled to explore how we may best understand and address these needs in the larger effort to promote health and healing for all urology patients. We conducted a SDOH screening pilot across 2 urology clinics in Charlotte, North Carolina aiming to evaluate the feasibility of implementing a social needs screening and referral program. Here, we describe our pilot program and share key takeaways based on our experience on the relevance and optimization of social needs screening in a urological setting.⁷

Screening Implementation

The pilot was conducted across 2 urology clinics that are part of Atrium Health, which houses a tertiary care academic medical center in Charlotte, North Carolina. At Clinic 1, roughly 10% of patients are either enrolled in Medicaid or uninsured, while over 50% of the population at Clinic 2 are enrolled in Medicaid or uninsured. It is important to note that Clinic 2 is the only urology clinic in the city specifically set up to serve uninsured patients.

We structured our pilot after the validated WE CARE model, a pediatrics SDOH screening and referral program. The model involves an SDOH screening, community resource information sheets if positive for ≥1 SDOH domains and optional followup with navigators as requested.⁸ Patients were screened with the validated North Carolina Department of Health and Human Services (NCDHHS) SDOH screening tool to address food, housing, utilities, transportation, interpersonal safety and the urgency of needs. A convenience sample of 40 patients was engaged at each clinic for screening for a total of 80 patients. A followup survey was sent to all staff and clinicians who participated in the pilot with focused questions to assess perceptions and feedback. Implementation involved multiple operational components; thus, we developed a standardized workflow in alignment with the WE CARE model (fig. 2).

Figure 2. Workflow design for social determinants of health screening implementation.

Findings

Among 80 patients screened, 39% (31/80) were White, 43% (35/80) were Black and 14% (11/80) were Hispanic. We observed a high burden of need among patients, particularly those at Clinic 2 (see table). Across both clinics, 30% screened positive for ≥1 need in any domain, with food and housing being the most frequently indicated needs. Over half of the patients who screened positive for ≥1 social need requested additional follow-up with a patient navigator for further support.

We assessed clinical and staff feedback using surveys sent to those who participated in the screening pilot. All respondents either agreed or strongly agreed among other things that screening was valuable and allowed them to better understand the needs of their patients, aligns with departmental goals and mission, and is moderately to highly feasible.

Future Insights

Through this pilot, we learned that successful screening for SDOH requires not only fine-tuning workflow, but beyond that involves a paradigm shift wherein urologists expand their scope of care delivery and role as providers. Here, we share several insights based on our pilot to optimize implementation and highlight the relevance of SDOH screening in urology as we look to the future of urological care.

Screening for social need was overall feasible, and we discovered facilitators to leverage and barriers to reduce. Provider buy-in around screening was advantageous, which we believed to be propelled by our collective mission to improve health and advance healing for all urology patients. Additionally, time-minimizing components including readily available resource guides and having screeners filled out in the waiting room enhanced workflow. Adopting electronic components and increasing language accessibility of screeners and resource guides could further ease workflow and increase accessibility for patients.⁹ Finally, we observed a high number of patients request additional support with a patient navigator, underscoring the importance of planning to ensure proper care is available for patients in terms of resources and personnel prior to implementation.¹⁰

Given the high level of need we observed, our results draw attention to the relevance of expanding screenings outside of primary care into other subspecialties. While screenings have occurred largely within primary care, 28% of the population in the county we screened do not regularly see a primary care provider.¹¹ Additionally, our findings demonstrated complex needs among patients. Taken together, we see that tackling social needs should not rest solely on primary care providers, but rather could be addressed by physicians across specialties.

Overall, a great opportunity and onus exists for urologists to explore addressing SDOH within our practice. Larger studies of urological patient populations are needed to further explore SDOH screening and will allow us to better relate the impact of SDOH on patient outcomes, which can be used to collaborate efforts to address SDOH within and across health care systems. Additionally, continuing education is needed for SDOH and health equity for providers, including subspecialists. As we learned from this pilot, we have only scratched the surface of tackling social need within urology, and we remain energized to continue this work toward better urological care for all.