Screening and Treatment of the Social Determinants of Health: Who Is Documenting in the Electronic Health Record?

Background: The social determinants of health (SDOH) are widely understood to profoundly influence healthcare access and outcomes. This awareness has prompted health systems to implement strategies to screen for and address SDOH. However, minimal research has examined which healthcare workers screen for SDOH, who addresses related needs, and how screening/interventions are incorporated into clinic workflows. Electronic health records (EHRs) present a promising data source for tracking when, how, and by whom SDOHs are addressed. A recent report by the National Academy for Science, Education, and Medicine (NASEM) suggests social workers play a central role in providing social care and addressing SDOH but further research is needed to verify the claim. This study assessed the feasibility of using EHR data to understand the workforce attending to patients SDOH, the process used, and the interventions implemented.

Method: To identify notes in which SDOH were documented, the Electronic Medical Record Search Engine (EMSERE) was used. EMERSE searches EHRs through key words to identify specific patient pools. Term bundles were developed and tested to identify patient notes related to food and housing insecurity. Analysts pulled EHR notes that documented food or housing insecurity from a sample of patients from within a large health system over a one-year period. From these, a random sample of notes (n=120, 60 for food insecurity and 60 for housing insecurity) were selected, extracted, and analyzed.

Results: Patients averaged 52 years of age (SD=16), were slightly more likely to be female (53%) and tended to be white (49%) or black (40%). While not every identified SDOH corresponded to an action, 72% of EHR notes documented an intervention was provided. Interventions addressing food insecurity were more likely to be documented than interventions for housing insecurity (78% versus 65%). For food insecurity, social workers provided 62% of interventions followed by dieticians (15%). Regarding housing insecurity interventions, social workers provided 64%, physicians 10%, and the remaining 26% were provided by other providers such as chaplains, nurses, and care manager assistants.

Conclusions: Addressing the SDOH is a crucial part of providing comprehensive health care. According to EHR data, social workers are the workforce most likely to address patients SDOH in health care settings. Social workers are leading the charge to meet patient needs and additional research to demonstrate the effectiveness of social care interventions is needed, as are policy changes and reimbursement mechanisms to further support the deployment of social workers in health settings.