Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review

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Figure 1.
Summary of the literature search and review process.

Table 1.

Key Terms Related to the Integration of Social Care Into the Delivery of Health Care

Term	Definition
Social determinants of health	The conditions in which people are born, grow, work, live, and age that affect a wide range of health, functional, and quality of life outcomes and risks
Social risk factors	Social determinants that may be associated with negative health outcomes, such as poor housing or unstable social relationships
Social needs	A patient-centered concept that incorporates a person’s perception of his or her own health-related needs
Social care	Activities that address health-related social risk factors and social needs
Social services	Servs ices, uch as housing, food, and education, provided by government and private, profit, and nonprofit organizations for the benefit of the community and to promote social well-being

Note: Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, DC. National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. https://doi.org/10.17226/25467

Table 2.

Activities for Integrating Social Care Into the Delivery of Health Care

Activity	Definition	Transportation-Related Example
Awareness	Activities that identify the social risks and assets of defined patients and populations; the foundation on which all other activities are built	Ask people about their access to transportation
Adjustment	Activities that focus on altering clinical care to accommodate identified social barriers	Reduce the need for in-person health care appointments by using other options such as telehealth appointments
Assistance	Activities that reduce social risk by providing assistance in connecting patients with relevant social care resources	Provide transportation vouchers so that patients can travel to health care appointments; vouchers can be used for ride-sharing services or public transit
Alignment	Activities undertaken by health care systems to understand existing social care assets in the community, organize them to facilitate synergies, and invest in and deploy them to positively affect health outcomes	Invest in community ride-sharing or time-bank programs
Advocacy	Activities whereby health care organizations work with partner social care organizations to promote policies that facilitate the creation and redeployment of assets or resources to address health and social needs	Work to promote policies that fundamentally change the transportation infrastructure within the community

Note: Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, DC. National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. https://doi.org/10.17226/25467

Table 3.

Article Characteristics (N = 18)

Table 4.

Studies’ Collection of SDOH Data and Use of Data Sources to Identify and Address Social Needs (N = 18)

Aspect of Data Collection	Studies Identifying Social Needs, No. (%)	Studies Addressing Social Needs, No. (%)
SDOH data collected
Demographics	13 (72)	5 (28)
Household income	7 (39)	1 (6)
Health insurance status	2 (11)	1 (6)
Tobacco use and exposure	1 (6)	0 (0)
Depression	2 (11)	0 (0)
Education and learning	3 (17)	1 (6)
Financial resource strain	1 (6)	0 (0)
Intimate partner violence	0 (0)	1 (6)
Physical activity	3 (17)	1 (6)
Social connections and social isolation	2 (11)	0 (0)
Other	11 (61)	15 (83)
Personnel responsible for eliciting SDOH data
Data analyst	8 (44)	2 (11)
Medical residents	1 (6)	2 (11)
Registered nurses	0 (0)	1 (6)
Social workers	2 (11)	2 (11)
Other	10 (56)	13 (72)
Data sources used
Census data	12 (67)	6 (28)
Community-level data	6 (33)	2 (11)
Table surveys	1 (6)	1 (6)
Paper questionnaire methods	4 (22)	4 (22)
In-person interviews	2 (11)	2 (11)
Other	7 (39)	9 (50)
Were GIS or geospatial data used?
Yes	15 (83)	3 (17)
No	3 (17)	15 (83)

Table 5.

Studies’ Use of GIS Methodologies for Each Integration Activity

GIS Methodology	Awareness	Adjustment	Assistance	Alignment	Advocacy
Geocoded (or obtained geocoded) data from publicly available resources	Yes^4,12	No	No	Yes¹²	Yes¹²
Geocoded (or obtained geocoded) data and aggregated patients’ residency addresses to census data	Yes^{10-16,18,19,21-23}	No	No	Yes^12,22	Yes¹²
Used GIS tools for spatial visualization of EHR and publicly available data	Yes^{8,10,12,13,18-23}	No	No	No	No
Created a geospatial data repository of neighborhood-specific online resources	Yes^17,24	No	Yes^17,24	No	No
Used data analysts to elicit SDOH data	Yes^{4,13-15,17,18,22-24}	No	No	No	No
Engaged social workers to elicit SDOH data	Yes⁸	No	No	No	No