Data to Care: Utilizing Assessment Tools for Health Departments to Address Social Determinants of Health

Many healthcare practices and providers across North Carolina are increasingly recognizing the significant impact of social determinants of health (SDOH) on patient outcomes. There’s a growing movement to systematically address these factors, and while routine screening for unmet health-related resource needs isn’t yet universal, many are moving in that direction and seeking standardized approaches. To meet this need, the North Carolina Department of Health and Human Services (DHHS), in collaboration with diverse stakeholders, has developed a standardized set of SDOH screening questions – a valuable Data To Care Assessment Tool For Health Departments and healthcare providers alike.

This initiative represents a crucial step towards integrating social care into healthcare delivery. By systematically collecting data on patients’ social needs, health departments and providers can gain actionable insights to improve patient care and community health outcomes. This article delves into the development, implementation, and significance of this data to care assessment tool, highlighting its potential to transform how health departments address SDOH.

The Imperative of Addressing Social Determinants of Health

Social Determinants of Health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These determinants, such as food insecurity, housing instability, lack of transportation, and interpersonal violence, can have a profound impact on an individual’s health, often outweighing the influence of medical care alone.

Recognizing this, proactive health departments and healthcare providers are moving beyond the traditional clinical setting to address these root causes of health disparities. Screening for SDOH is the first critical step in this process. It allows for the systematic collection of data that can inform interventions and resource allocation, making it a vital component of a data to care assessment tool strategy.

Development of a Standardized SDOH Screening Tool: A Collaborative Approach

The development of the North Carolina SDOH screening tool was a collaborative and iterative process, driven by the need for a consistent and effective method to identify patient needs. DHHS engaged with key stakeholders across the state, including medical practices, community organizations, and subject matter experts, to ensure the tool was practical, relevant, and evidence-based.

Key stages in the design process included:

• Stakeholder Engagement: In the summer of 2017, DHHS convened meetings with stakeholders already working on SDOH initiatives to understand best practices and identify areas where departmental support was needed. This initial phase ensured the tool would be user-centered and address real-world challenges.
• Best Practices Review: DHHS conducted a thorough review of existing SDOH screening tools and best practices in the field. This research informed the selection of relevant domains and question types, leveraging established methodologies.
• Priority Domain Identification: Based on research and stakeholder input, four priority domains were identified as critical areas to address:
  1. Food insecurity
  2. Housing instability
  3. Lack of transportation
  4. Interpersonal violence
     These domains were chosen because of strong evidence linking them to health outcomes and the availability of community resources to address identified needs.
• Technical Advisory Group (TAG) Formation: A Technical Advisory Group (TAG) comprising diverse subject matter experts and stakeholders was convened in the winter of 2017-18. This group played a crucial role in defining design principles, reviewing existing tools, and reaching a consensus on the final set of screening questions. The TAG ensured the tool’s validity and applicability across diverse settings.
• Question Adaptation and Selection: The screening questions were carefully selected and adapted from validated tools like the Hunger Vital Sign and PRAPARE (Protocol for Responding to Assessing Patients’ Assets, Risks, and Experiences) assessment tool, and HARK (Humiliation, Afraid, Rape, and Kick) questionnaire. This adaptation ensured the questions were evidence-based and tailored to the North Carolina context.

Design Principles Guiding the Tool Development

The development of the standardized screening questions was guided by several key design principles, ensuring its effectiveness and usability as a data to care assessment tool:

1. Evidence-Based and Actionable Domains: The tool focuses on domains with strong evidence linking them to health outcomes and where community resources are available to address identified needs. This principle ensures that screening efforts lead to tangible interventions and improved patient well-being.
2. Simplicity and Brevity for Broad Applicability: Questions are designed to be simple, brief, and applicable to diverse populations and settings across the state. This ease of integration into various workflows is crucial for widespread adoption. The tool is intended as an initial screen; positive responses trigger more in-depth assessment and resource navigation.
3. Validation and Accessibility: Questions are drawn from best practices and validated tools, written at accessible reading levels to ensure effective use across diverse populations. This focus on accessibility enhances the tool’s inclusivity and effectiveness.
4. Alignment with Existing Tools: The questions were intentionally aligned with existing screening tools (e.g., PRAPARE, Bright Futures Questionnaire) to promote easier implementation and data collection consistency. This alignment reduces burden for providers already using other screening tools and facilitates data comparability.

Key Domains and Sample Questions

The standardized SDOH screening tool focuses on the four priority domains, with questions designed to be brief and easily understood by patients. Examples of the questions within each domain include:

• Food Insecurity: Modified from the Hunger Vital Sign, questions aim to identify families at risk of food insecurity.
• Housing/Utilities: Adapted from PRAPARE, questions identify individuals experiencing homelessness or at risk of losing housing.
• Transportation: Adapted from PRAPARE, a single question assesses transportation barriers.
• Interpersonal Safety: Adapted from PRAPARE and HARK, questions address exposure to intimate partner violence, elder abuse, and child abuse.

These questions serve as a starting point for a more comprehensive understanding of a patient’s social needs, providing health departments with valuable data for care assessment and intervention planning.

Field Testing and Key Findings: Validating the Data to Care Assessment Tool

To ensure the practicality and effectiveness of the standardized screening questions, DHHS conducted a field test across 18 clinical settings and telephonic case management settings in Fall and Winter 2018-2019. This field test involved 804 patients and 735 clinic staff members and aimed to evaluate:

• Questionnaire Length: Assessing whether the length of the screening tool was manageable for patients and providers.
• Ease of Understanding: Evaluating if the questions were easily understandable for patients from diverse backgrounds.
• Comfort with Asking and Answering: Gauging comfort levels for both providers asking the questions and patients answering them.

The field test results provided valuable insights into the tool’s usability and acceptance, informing further refinements and demonstrating its viability as a data to care assessment tool. The positive feedback from both patients and staff underscored the tool’s potential for widespread adoption.

Implementation and Use in Health Departments: Leveraging Data for Actionable Care

While DHHS is not mandating SDOH screening for all providers at this time, they strongly encourage practices, providers, social services agencies, and community organizations to utilize this standardized tool. For health departments, this data to care assessment tool offers a powerful mechanism to:

• Systematically Collect Data: Implement routine SDOH screening to gather consistent data on the social needs of their communities.
• Inform Program Development and Resource Allocation: Use the collected data to understand prevalent social needs and tailor programs and resource allocation to effectively address these needs within their jurisdiction.
• Measure Impact and Improve Outcomes: Track data over time to measure the impact of interventions and continuously improve strategies for addressing SDOH.
• Integrate with Care Management Approaches: In the context of Medicaid Managed Care in North Carolina, Prepaid Health Plans (PHPs) are required to integrate these screening questions into their care management approaches. Health departments can similarly integrate this tool into their public health programs and initiatives.
• Promote Statewide Data Collection and Analysis: Standardized screening facilitates statewide data collection, enabling a comprehensive understanding of unmet health-related needs across North Carolina. This aggregate data can inform policy, planning, and investments at the state level.

NCCARE360: Connecting Data to Resources and Care Coordination

Recognizing that screening is only the first step, North Carolina has invested in NCCARE360, a statewide coordinated care network. This platform is designed to electronically connect individuals identified with social needs through screening with relevant community resources. NCCARE360 facilitates:

• Referral and Navigation: Streamlining the process of referring individuals to appropriate social services and community-based organizations.
• Feedback Loop: Enabling a feedback loop to track the outcomes of referrals and ensure individuals receive the support they need.
• Comprehensive Care Coordination: Improving care coordination across healthcare and social service sectors, leading to more holistic and effective interventions.

NCCARE360 complements the SDOH screening tool by providing the infrastructure to act upon the data collected, truly transforming screening data into actionable care. This integration is crucial for realizing the full potential of the data to care assessment tool approach.

Conclusion: Empowering Health Departments with Data-Driven Strategies

The North Carolina standardized SDOH screening tool represents a significant advancement in the effort to address social determinants of health. This data to care assessment tool empowers health departments, healthcare providers, and community organizations to systematically identify and address patients’ social needs. By embracing standardized screening and leveraging platforms like NCCARE360, North Carolina is paving the way for a more equitable and effective healthcare system that considers the whole person – their health and their social circumstances. The widespread adoption of this tool promises to enhance data-driven decision-making, improve resource allocation, and ultimately contribute to healthier communities across the state.