Social Determinants of Health

Webinar (series)
Private Practice Simple Solutions: Social Determinants of Health
Jul 25 - Aug 22, 2023

Laura J. Zimmermann, MD, DipABLM, MS, FACP, discusses social determinants of health (SDOH), the impact of social needs on private practices, methods to understand the unique health needs of a community, and strategies to help your practice begin addressing SDOH. The session is part of Private Practice Simple Solutions, a presentation of the AMA STEPS Forward®️ Innovation Academy. 

Using the AMA STEPS Forward® Social Determinants of Health toolkit as a guide, this four-week learning session addresses how to define social determinants of health, the impact of social needs on private practices, understanding the unique health needs of a community, and strategies to help your practice begin addressing social determinants of health.


  • Laura J. Zimmermann, MD, DipABLM, MS, FACP, interim division chief, general internal medicine; associate professor of preventive medicine and internal medicine, Rush University Medical Center

Host: Hello and thank you for joining us today. Welcome to the American Medical Association’s Private Practice Simple Solutions, part of the Steps Forward® Innovation Academy. Before we get started with the content, a quick few housekeeping items. The Private Practice Simple Solutions program is a series of rapid learning cycles designed to provide opportunities to implement actionable changes that can immediately increase efficiency.

Please note that this presentation has been recorded and is for informational purposes only. You should consult a professional advisor for specific medical, legal, financial or other advice. Please take the moment to carefully review this notice. I’d like to now introduce today’s speaker, Dr. Laura Zimmerman, who will lead us through the content today. Dr. Zimmerman, go ahead and take it away.

Dr. Zimmerman: All right, thank you. Very excited to be joining you to discuss practical solutions for implementing social determinants of health screening and linkage to resources in a primary practice setting. Addressing social determinants of health is critical to the health of patients, communities and the viability of our health systems. It can be done on different scales by individuals or systems, and we will discuss practical tactics to bring this into your practice. Although a systematic approach is key, it doesn’t necessarily have to be a heavy lift. We’ll discuss some of the resources you may already have at your fingertips.

So social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship and age that affect the quality of life and a wide range of health outcomes. Different organizations have divided the social determinants of health or social drivers of health into various categories. Pictured here is the U.S. Health and Human Services’ Healthy People 20-30 classification.

So why address social determinants of health? We know that the health care that we as physicians and health systems provide for patients is but a fraction of the factors that influence health and well-being, mortality and morbidity. The other major contributors are health behaviors and lifestyle, as well as the physical and built environment and various societal and socioeconomic factors. These latter categories are the social determinants of health.

And why address social determinants? Well, social determinants of health have major implications for multiple outcomes of importance to clinicians, health systems, payers and most importantly, our patients.

Sorry, we already, I already went through this. So these are the various outcomes that are affected by social determinants of health. In the next slide, if you’re interested in diving into the evidence, the Patient-Centered Outcomes Research Institute, a.k.a. PCORI, has an online evidence map which you can explore. You can choose the social need you would like to examine, the study population, the intervention setting and the resulting outcomes. For example, this search shows the food security assistance in Medicare Medicaid enrollees has been shown to decrease emergency room and urgent care visits but did not demonstrate improvement in medication adherence thus far.

Addressing social determinants of health is obvious in the context of the ethos of our profession. As physicians, we see clearly the impacts of unmet social needs on our patients every day. Addressing SDOH is clearly the right thing to do for patients and communities, but there is also growing additional financial incentive to do this effectively.

In the last decade, value-based purchasing and accountable care organizations have increasingly required an incentivized screening and referral related to unmet social needs. This further motivates health systems to go beyond the exam room, beyond traditional biomedical models of disease to address unmet social needs. Commercial, value-based contracts have also begun providing nutrition, transportation and housing support. In my institution at Rush, we are participating in Medicare’s ACO REACH, which requires SDOH screening and linkage to resources as part of the strategy to promote health equity.

The AMA has put together a module as part of the Steps Forward® series that provides step-by-step guidance for implementing SDOH screening and linkage to resources in practice. We will briefly go through each step here and discuss how it can be applied to the private practice setting.

First, understand and engage the communities your practice serves. Are you on staff at a local hospital? Is there a hospital or health system that your patients go to for subspecialty care or procedures? Additionally, if you’re part of a clinically integrated network or an ACO, some kind of aggregator, what are the hospitals in those networks? To get a sense of the community’s needs, you can access your affiliated hospital’s community needs assessment report and/or their community health improvement program.

Federally tax-exempt hospitals and health systems are required to conduct community health needs assessments every three years. Hospitals typically collaborate with local public health departments and seek community input to conduct these analyses. The report is posted on each hospital’s website and often includes information about the populations and communities that the hospital serves. The report typically identifies health and social disparities and prioritizes issues of concern for the communities.

Accompanying the community health needs assessment, the system must also formulate a community health improvement program that outlines how the hospital will address the highlighted gaps and issues. Additionally, you can look around your patients’ communities yourself. What are the community-based organizations or government offices that are present? Examples may include Catholic charities, a food depository, WIC offices, places of worship, et  cetera. You can make contact with these organizations to deem which social determinants of health to focus on to have the most impact for your patients.

Next, engage different levels of leadership within your practice and within the hospital or aggregator such as an ACO or clinically integrated network that you may be participating in. Within the practice, it will be important to start a discussion with the partners and owners of the practice, as well as the practice manager and the staff leaders.

Simply starting the conversation can be a great first step. At the first meeting you can discuss the content of the first few slides here. What are social drivers of health? Why is it important to screen for and address SDOH? How does this help our patients? Why do governments, payers and health systems care about this? Last, bring any information you found so far about specific targets and interventions. Bring community health needs assessments, community health improvement programs, or your own observations and exploration in the community to share with the practice leadership.

When engaging leadership in the hospital, ACO or clinically integrated network that you belong to, you may simply start by asking for a meeting to review the Community Health Needs Assessment, the Community Health Improvement Program, or the different value-based metrics for the ACO or clinically integrated network in which you’re participating.

Let the leadership know that your goal is to figure out how your practice can help them meet their goals. Try to figure out what matters to the aggregator or health system. What are the metrics by which they are being evaluated? How can screening for and addressing social determinants of health help?

So next dig in deeper regarding the readiness to take this on. As we alluded to in engaging leadership, defining the perceived value of social determinants of health screening within your practice or within the ACO or clinically integrated network can be key. So you want to find those mutual priorities.

Financial readiness plays into this in that there may actually be financial incentives for screening for social determinants of health and linking people to resources. You can minimize financial risk by incrementally building on existing staff and workflows, and you can use things like calculating a return on investment in order to make the case to leadership that their investment in this type of program matters.

Next, look for executive sponsorship. You will definitely want a practice-level champion. That might be the owner or the partner or a different physician in the practice. You’ll also want to go to health, hospital and health system executive leadership as well as leadership of the ACO or CIN. You want to identify someone who will publicly sponsor this effort and send the message to the team and stakeholders that this is a priority.

Next, start to think about the role of your clinic team members. Are there additional team members that you need? Many private practices do not have navigators or community health workers. But when thinking about your relationship to a health system, ACO or clinically integrated network, is there a way for your patients to access these resources through those aggregators? We often think of these team members as being a connection between the patient and the resource.

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But you can also check with community partners. Do they have CHWs, navigators or even social workers that can help once the patient has been connected to the community organization through your office? In terms of project management, think about who will store and own the data. A practice manager? Perhaps your RN manager? Perhaps the physician champion will be the one to do this. If you have learners, medical students or other learners and trainees who rotate through your office they may also be candidates for doing the project management.

Check out organizational infrastructure. Again, are there things that the ACO or the clinically integrated network can lend to this effort? Are there data that are already being gathered at a practice level or at the level of the ACO or clinically integrated network? They may also have care management resources, particularly if you’re participating in an ACO.

All right. So the next step is selecting and defining your plan. So the iterative process of the Plan-Do-Study-Act cycle is a great way to formulate an intervention, measure the impact, refine your processes and then try again or scale. Start with these plan components and keep it very focused at first. I recommend that the champion within the practice draft the plan, get buy-in from the executive sponsor and then take the plan to all clinical team members and stakeholders for input.

First, determine a short menu of candidates’ social needs to focus on based on the community health needs assessment, the community health improvement plan, or your own reconnaissance within the communities that you serve. Take this short menu to the practice leadership or sponsor and the practice clinical team for impact. Stay focused. When you’re starting out, just choose one social determinant or social driver to focus on.

Next, think about a specific target subgroup of patients. Maybe you’ll focus on Medicare patients with diabetes, maybe you’ll focus on one physician’s patients to start. Perhaps you will start by only screening on Tuesday afternoons. Choose a patient subgroup that is feasible and easy for staff to identify and engage.

Next, define your metrics. What are things we need to measure to know that we are having an impact? First, establish that the target population subgroup is indeed being screened. Then measure how many of those patients screen positive. In this instance, we chose food insecurity as our focused social need. You’ll want to measure the people who have screened positive and then we want to make sure that what we’re doing is actually having an impact on patients, so we’ll want to also measure the percentage of people who are linked to resources and then choose something that is time-limited, so in this instance, we’ll look at the data every two weeks.

So for those who do screen positive, what is the intervention? In this example, we will give people contact information for the local food depository, and one of our medical assistants will call the patient two weeks later to see if the patient contacted the depository and whether they were able to access assistance.

Next, design a workflow that’s feasible and easy. Think low-hanging fruit, simply building on existing workflows. Although EPIC and other EHRs have existing tools for social determinants of health screening, and large health systems like Rush build their own, you don’t necessarily have to get that resource-intensive right off the bat. You can simply start with a paper questionnaire.

Last but not least, how will the data be collected and managed? So in this instance we decide, all questionnaires go to the practice manager who will keep a password-protected Excel spreadsheet—medical assistants will log follow-up calls there.

So once you’ve got your plan, start to get even more nitty gritty about the specifics. When assessing social determinants of health at the patient level, there are a variety of common free screening tools that are available. PREPARE is an effort that was put together by the National Association of Community Health Centers and other stakeholders. They came together to develop tests and spread a national standardized patient-centered SDOH assessment tool that is free and accessible online.

The EveryONE Project is a collaboration with the American Academy of Family Physicians and others, which includes a variety of different dimensions of promoting health equity, including social determinants of health. They have an entire guide to social needs screening with tools and resources available.

We’ll look at the Accountable Health Communities Health-Related Social Needs Screening Tool. The Oregon Community Health Information Network also has a variety of data and resources available. And last, SIREN, the Social Interventions, Research and Evaluation Network, is a collaboration within the Center for Health and Community at the University of California, San Francisco, which provides various tools online, but will also provide evaluation, research and analytics for safety net and mission-aligned health systems who are implementing this.

On the next slide, the Accountable Health Communities Health-Related Social Needs Screening Tool, this screening tool is hosted by the CMS Innovation office and is compliant with most CMS-ACO reporting requirements. So this is an excellent, easy-to-use resource as well.

To give an example of how we do this at Rush, we developed a workflow that provides many different touch points for patients to complete screening. Patients can complete screening through the My RUSH app during e-check in. If they don’t use e-check-in, they can fill out the screener at a kiosk in the waiting area. This is confidential and private. If this isn’t completed, then the medical assistants screen the patient for SDOH during our rooming protocol. A positive screen will trigger a clinical reminder for the physician, which initiates an order set which adds the Z codes to the visit and prompts the physician to ask the patients if they’d wish to speak with a social worker. Additionally, resources will print on the patient’s after-visit summary automatically.

So this is a great segue into the next step. Once you screen patients for social determinants, you want to link them to resources. This is a very important step because you want to make sure that if you identify a need, you’re actually able to address it.

Think about screening for social determinants like disease screening that we do in medicine. We screen for diseases that have a certain prevalence that we’re likely to find and that we have an ability to do something about. We screen for things where we have an ability to change the outcome. The same applies to SDOH screening. And in fact, screening for SDOH without the ability to link patients to resources can actually do harm because you risk stigmatizing the patient without actually helping them.

If you don’t have a social worker or CHW at your practice or have access to them through an ACO or clinically integrated network, 211 is a great resource for linking patients with unmet social needs to resources. By simply dialing 211, callers are routed to referral specialists who can then match them to available resources and make direct referrals to organizations that are geographically proximal to them. People can also go to this website and get plugged into this network.

There are also proprietary services that can be geographically tailored to help locate resources in patient communities. These have some out-of-the-box functionality but are often most successful when a practice or health care organization has a relationship with community organizations involved. This is an example of something to bring up when you meet with the hospital, ACO or clinically integrated network leadership. Do they have an existing contract with a service like NowPow, and is that something that your practice may be able to be included in?

Another point to remember, if you do establish a community partner, such as a local food depository, you have to be careful not to overwhelm them with referrals. At Rush, we work with our community partners to develop their capacity so that the relationship is mutually beneficial.

If you’re simply sending patients without supporting the partner, you risk placing additional strain on a community organization that may have limited resources in general, thus threatening their sustainability and ultimately their ability to help your patients.

Alright, so evaluate and refine. So you’ve formulated a plan for screening for social determinants of health and linkage to resources. Next, you want to do the intervention. Then you want to study what you have done. So a priori we set out to measure the percent of eligible patients screen, the percent of positive screens, and the percent of patients enrolled at the food depository or other assistance.

Next, get the team feedback. What’s working? What isn’t? Also, get the perspective of your community partner. Are most of the people that we’re sending your way qualifying for your service? What’s the volume like? Is this straining you? Are we overwhelming your capabilities?

You want to get feedback about messaging to the patients about the service. You want to get patient feedback: Was this helpful? How can we make this more helpful? How can we make this process easier?

Last, you want to get health system, ACO or clinically integrated network feedback. Over time, you’ll want to see if their metrics have changed. Are they seeing fewer avoidable emergency room visits from your patient panels, for instance?

Last, you want to act. So after asking all of these questions and collecting all of this data, you want to refine what you’re doing based on these data to improve your outcomes. And then you start the cycle again.

So last but not least, celebrate your successes. So share the stories. Data is great, but it’s the narrative and the human story that really makes the impact and reinforces the importance of these efforts to the clinical team members and other stakeholders. Recognize champions and supporters. Share best practices, wins and learning opportunities within your own organization and within the region. And lastly, consider submitting data to local and national conferences because many practice and care settings across the country are starting to incorporate SDOH screening into their workflows.

Speaker: Alright, thank you for your time today, Dr. Zimmerman. That was a great presentation. I’d just like to point out that her office hours are going to be Thursdays from 9 to 10, and we encourage you to discuss and engage with your peers and doctors on the discussion board that’s linked here. She’ll be checking in at least once a week and that’s when you can kind of expect some answers to any questions or comments that you may have. You can also check out additional resources on the STEPS Forward®️ website. Thank you for joining us.

    Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.