Health Organizations Must Act, Urge Equity Experts
SAN DIEGO—If health systems provide quality care only to those with privileged access, can it be considered quality care at all? Speakers for the ACR Convergence 2023 session Addressing Social Determinants of Health: A Journey Toward Health Equity challenged their audience to consider this question and provided expert guidance concerning the implementation of health equity measures in medical organizations.
What Are Social Determinants of Health?
Dr. Rose-Smith
“We all will achieve health equity when each individual has the opportunity to have and acquire their best health without barriers, such as race, ethnicity, income and gender identity,” said Jillian Rose-Smith, PhD, MPH, LCSW. Dr. Rose-Smith is the vice president and chief health equity officer of the Hospital for Special Surgery’s Department of Social Work in New York City, where she provides operational leadership for access to care and other DEI projects. For health equity to be achieved, “we’ll need to do more than talk and think about health equity. … We’ve been having this conversation for three-and-a-half decades,” and still haven’t rectified the massive, well-documented disparities in care.
In 2017, the National Quality Forum (NQF) published the Road Map to Health Equity guideline.2 The NQF provided instructions to hospitals and health plans on how to prioritize equity, as well as guidance for clinicians, who can connect individual patients with community support services. It also called on policymakers to incentivize equity measures. According to Dr. Rose-Smith, this resource led to conversations, but not a lot of direct change.
In 2023, regulatory bodies took a more direct approach. At the federal level, the U.S. Department of Health and Human Services identified equity as a goal in its strategic plan and published an equity action plan. The Centers for Medicare and Medicaid Services (CMS) has been updating its quality reporting programs to include health equity and incentivize hospitals to provide care to under-represented populations, such as unhoused people. The CMS Joint Commission in Minority Health dictates equity mandates to hospitals and other health organizations, with more than 30 mandatory standards for health equity, such as adequately screening patients. Health organizations held to these standards must demonstrate that they have an equity plan in place and the ability to implement it or face a financial penalty. Dr. Rose-Smith added that one of CMS’s top priorities is to collect, report and analyze data concerning social determinants of health.
Dr. Rose-Smith closed with a few recommendations to medical professionals. For example, clinicians can document Z codes in each patient’s electronic health record. (Note: Z codes are an International Classification of Disease subset used to capture factors that influence health status and contact with health services and can facilitate Medicare reimbursement.) She also emphasized the importance of community partnerships and outreach.
Screening for Social Determinants of Health
Ms. Flores
Melissa Flores, MPH, MSW, assistant director of the Office of Health Equity at the Hospital for Special Surgery, oversaw her workplace’s yearlong process of developing and implementing a comprehensive social determinants of health screening process. She observed that her hospital has experienced a culture shift in the past few years, with the creation of a new Office of Diversity, Equity and Inclusion (DEI) in 2020 and an Office of Health Equity in 2023.
The process began with a multidisciplinary workgroup dedicated to developing a standardized strategy for addressing social determinants of health. This team met biweekly and collaborated to decide on a phased approach to both screening and intervention. In 2022, it implemented a pilot project in the outpatient and pediatric departments, in which screenings were conducted via paper-based materials. The following year, an electronic component was rolled out and expanded to the inpatient adult sections of the hospital. Finally, the effort expanded to include the ambulatory adult areas as well.
When standardizing the screening questions, the workgroup considered several accredited screening tools, including Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) and the ACH Health-Related Social Needs Screening Tool. Ultimately, the team combined elements from several tools into a simple questionnaire featuring eight multiple choice questions. Each question addressed one significant social determinant of health: food insecurity, housing, utilities, transportation, interpersonal safety, employment, health literacy and income.
The workgroup’s next priority was workflow design. They determined which staff would have responsibility for implementing screenings and how the data would be collected and documented. Information would be collected from patients at multiple points before, during and after their appointment, including via the online patient portal and the check-in kiosk. If a patient screened positive on any of the domains, specific resources would appear on the patient’s after-visit summary. If a patient indicated their situation was urgent, social work and case management teams would be contacted to follow up.
Dr. Flores emphasized that this is a multidisciplinary team effort and requires support and input from many hospital departments. For example, IT collaboration is critical to ensuring the electronic questionnaire is accessible, easy to use, and links patients with the appropriate resources. The professional education department developed an educational program for nursing staff, including an online module and in-person training. The work group implemented an organization-wide communication plan, so that messaging regarding the screening could be standardized and relayed by hospital leadership. Once the screening was live, the workgroup had a week of daily huddles to immediately address concerns as they arose.
Dr. Flores emphasized that leadership must monitor the data and intervene when disparities are observed. Additionally, health organizations must ensure that resources are actionable for their marginalized patients. For example, a food pantry on site at the hospital can directly meet the needs of patients with food insecurity.
Conclusion
To improve healthcare access, treatments and outcomes for marginalized patients, health systems will have to undergo structural and organizational changes beyond screenings. However, ensuring that patient data is being collected and utilized properly, meeting mandatory health equity standards, and organizing towards health equity within one’s own organization are all steps toward a more equitable future.
Glen K. Rodman is the assistant editor of The Rheumatologist.
References
- Hood CM, Gennuso KP, Swain GR, et al. County health rankings: Relationships between determinant factors and health outcomes. Am J Prev Med. 2016 Feb;50(2):129–135.
- NQF issues quality roadmap for reducing healthcare disparities. National Quality Forum. 2017 Sep.
