Skip to main content
Dear Editors:
Screening for social determinants of health (SDH) is now being adopted by a growing number of health care systems across the United States. With scant evidence to support its effectiveness in improving health outcomes for individuals or populations, its use seems compelling given the strong role social, behavioral, and economic factors play in determining health outcomes.
For screening for SDH (more accurately termed ‘case finding’) to be effective and feasible, at least three conditions must be met: a) the condition must be reasonably prevalent, b) the condition must be amenable to interventions that improve outcomes, and c) resources and means to implement interventions must be available. Ideally, randomized controlled trials would provide the evidence informing best practices. Although some trials are ongoing (1), few of these criteria have been met to guide current efforts to screen for SDH in health care settings. There are compelling reasons to believe they will be difficult to achieve under current funding and organization of health systems and social service organizations.
In this context, the article by Greenwood-Ericksen and colleagues (2) on social needs screening in Michigan provides important, incremental insight into some important issues surrounding health systems’ efforts to address social determinants of health (SDH). Through a systematic series of interviews, authors investigated reasons for observed variation in screening for SDH among Federally Qualified Health Centers in Michigan. The high prevalence of SDH among patients at FQHCs made the study sites ideal for investigating influences on screening practices. Key findings included that screening practices were not evidence-driven, but influenced mainly by local and state policies, funding opportunities, leadership, and configuration of local practices. While screening tools were chosen from existing standardized instruments, implementation and follow up of findings varied across centers. Importantly, screening for SDH was part of a state initiative that included funding for Community Health Workers (CHWs), who were centrally involved in screening and follow up at the sites. Since all sites used CHWs, the incremental effect of CHWs on screening practices could not be studied.
While not designed to build evidence for best screening practices, the study by Greenwood-Ericksen and colleagues nonetheless provides relevant insights. First, standardized screening protocols across systems are desirable, to allow for meaningful comparisons. Second, within practices some variation from standard protocols will be necessary to accommodate local conditions among patients, health center resources, and leadership. Third, areas for improvement and further learning include integrating findings into electronic medical records so they can be routinely guide interventions and follow-up, and application of the findings to inform population-level interventions in a local geographic area.
The current frenzy of screening for SDH should be better informed by evidence to ensure effectiveness in improving health outcomes. We look forward to further studies like this, as well as randomized trials, to inform best practices to improve population health.
1. Accountable Health Communities. First Evaluation Report. December 2020. Smith LR. RTI International. Available at: https://innovation.cms.gov/data-and-reports/2020/ahc-first-eval-rpt. Accessed August 17, 2021.
2. Greenwood-Ericksen M, DeJonckheere M, Syed F, Choudhury N, cohen AJ, Tipirneni R. Implementation of health-related social needs screening at Michigan Health Centers: A qualitative study. Ann Fam Med July, 2021. 19(4):310-17. https://doi.org/10.1370/afm.2690
Brent C. Williams, MD, MPH
Medical Director, Complex Care Management Program
Michigan Medicine
Ann Arbor, Michigan
bwilliam@umich.edu