Results

Below is a summary of the three studies determined to be appropriate for in-depth analysis by the authors. Each of the three studies occurred during the COVID-19 pandemic and were published in 2023.

Roth et al. conducted a study to assess the impact of a multipronged strategy to influence both clinical outcomes and social determinants of health (SDoH) that affect type 2 diabetes. The project, called the Providence Diabetes Collective Impact Initiative, included multiple interventions such as outreach, diabetes selfmanagement education, screening and addressing SDoH [13]. The study comprised of 1,220 people (740 in the treatment group and 480 in the control group), aged 18 to 65 years old with pre-existing type 2 diabetes diagnosis who visited one of seven clinics in the tri-county area of Portland, Oregon between August 2019, and November 2020.

This pre/post interventional study measured SDoH screenings, participation in diabetes education, HbA1c test results, blood pressure, primary care utilization, inpatient and emergency department hospitalization. The data demonstrated patients in the treatment group had an increase in receiving diabetes education (15.5%, p<0.001), SDoH screening (4.36%, p<0.087), and average number of primary care visits (p<.001); however, there were no pre- post-intervention differences in HbA1c, blood pressure, or hospitalizations [13].

Gold et al. evaluated a six-month intervention of technical assistance and coaching with electronic health records to improve the documentation of social risk screening and subsequent social service referrals in community health centers. The intervention was carried out in 31 clinics [14].

The data demonstrated the monthly clinic rate of social risk screening was 2.45 times (95% CI, 1.32-4.39) higher during the six-month intervention period compared to the preintervention period. However, this improvement was not sustained after the intervention period had stopped (rate ratio, 2.16; 95% CI, 0.647.27). The second outcome was the monthly clinic rate of social risk-related referrals which showed no statistical difference during or after the implementation of the intervention, even when patients had social risks documented.14 A secondary analysis of the study measured if the intervention affected diabetes control and diabetic care assessed by lipid panel checks, HbA1c screening, and blood pressure measurements. The intervention had no impact on diabetes outcomes.14 The article suggests the COVID pandemic, and the short intervention period may have impeded sustainability and statistical significance.

Joseph et al. (2023) evaluated the effect of a 24-week communitybased healthy lifestyle program on change in social needs and change in American Heart Association’s (AHA) Life Simple 7 (LS7) score. A total of 70 Black men from a large Midwestern city participated in the program. Researchers assessed social needs at 12 weeks and 24 weeks and changed the LS7 score from baseline to 12 and 24 weeks. More than half of the participants had at least one social need identified at baseline via the Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities Health-Related Social Needs Screening tool. While the percentage of participants with social needs was reduced during the program, there was no statistically significant association between social needs status and improved LS7 score [15].

Discussion

These authors set out to synthesize the published data connecting social determinants of health (SDoH) screening in patients with a diagnosis of hypertension or diabetes, and measured clinical outcomes related to chronic disease status and/or healthcare utilization. Our systematic review revealed a paucity of data with only three articles meeting our inclusion criteria. The inclusion criteria were developed to be broad enough to obtain the relevant research, but did not result in extensive unassociated articles. The scarcity of evidence found is a demonstration that this is a new area of research. This does not come as a surprise to the authors as the Joint Commission and CMS have only recently established quality standards related to SDoH screening as of 2023. This appears to be a very new approach to population health for healthcare systems and hospitals. Each of the studies reviewed had a multi-pronged intervention with a process for screening for SDoH, a pathway for referrals and/or resources to address adverse SDoH indicated from the screening, and the provision of medical care that incorporated social care.

Roth et al. [13] incorporated outreach and chronic disease selfmanagement education along with a process to screen and address SDoH. The study found the treatment group had an increase in receiving diabetes education, SDoH screening, and average number of primary care visits; however, there were no differences in HbA1c, blood pressure, or hospitalizations. This study was innovative as it examines the effectiveness of SDoH-related interventions in managing and improving outcomes associated with chronic conditions such as diabetes. The interventions were designed to address both clinical issues and social risk factors particularly among low-income Medicaid population of patients. The data from this study provides important insight into how to effectively improve diabetes management in a particular population. The researchers took a multi-pronged approach that included not just medical care, but also care coordination and chronic disease self-management education. Efforts to improve diabetic control are critically important to note given the prevalence, costs, and negative health outcomes associated with type 2 diabetes.

Another strength of the study was the use of the Electronic Medical Record system (EMR) to proactively identify patients with type 2 diabetes who had clinical care gaps. The SDoH screening was also built into the EMR. While the revised EMR included order sets to standardize diabetic care including referrals for additional clinical and social supports, the study does not address the extent to which the prompts are used by providers. The article suggests that primary care teams screened patients for SDoH using the questionnaire embedded in the EMR, but it is unclear whether a standardized screening process was followed. For example, there is no explanation about what stage during an appointment a patient is screened for SDoH and by whom. The article also contends that patients could self-refer to the community resource desk but does not share what proportion of patients self-refer versus are referred because of identified needs or referred by a member of the healthcare team for some other reason.

While the study assesses the rate of SDoH screening and referrals to the community resource desk, it does not consider whether those adverse SDoH identified in the screening are addressed, or whether the SDoH gap is closed. If patients receive referrals for a community-based resource, it does not necessarily mean that their need is met. This could be an explanation for why few clinical outcomes were observed.

Gold et al. [14] studied how providing technical assistance and coaching healthcare providers about SDoH screening and referrals affected the completion rate of SDoH screenings and diabetes control and care. While the data demonstrated an increased rate of SDoH screening during the six-month intervention period, the improvement was not sustained after the intervention stopped. There was no statistically significant difference in the rate of social risk-related referrals nor any measurable impact on diabetes outcomes.

Similar to the Roth et al. [13] study, the Gold et al. [14] study integrated the SDoH screening and referral process into the EMR. This integration provided access to discrete data and the ability to analyze screening rates and any associated clinical outcomes. The fact that documentation of the SDoH screening and referral workflows were not sustained post intervention indicates the process was not universally adopted or standardized across the clinics. Due to clinics being in under-resourced communities and serving a high population of low-income Medicaid recipients, it is likely that screening and referrals continued to take place, but clinical team members may not have accurately documented these activities in the necessary EMR fields.

The coaching and technical assistance intervention was clearly effective as it resulted in almost 2.5 times more SDoH screening compared to the six-month pre-intervention. The fact that this improvement was not sustained post intervention may mean that the intervention did not occur over a long enough period to be routinely adopted by the clinical care teams. It could be inferred that the clinical care team members responsible for the SDoH screening and referrals reverted to old, pre-intervention processes once the coaching and technical assistance ceased. The aforementioned may also indicate a failure in the administration of effective change management.

Significant to note that despite the increase in screening rates, the rate of social service referrals did not increase regardless of patient status and social risks identified. This could indicate a lack of attention to the referral process and knowledge about communitybased resources available to meet needs; or it could be indicative of an under-resourced community that lacks adequate support for social service referrals.

The intervention included a five-step implementation process: 1) leadership buy in; 2) set goals; 3) develop workflows; 4) orient staff; 5) implement and iterate. It is unclear which step(s) failed once the intervention ended. Further research is needed to understand exactly where the breakdown occurred so that effective change management processes can be improved and sustained.

In addition to analyzing the screening and referral rates, the researchers also conducted secondary analysis of clinical measures including cholesterol, HbA1c, and blood pressure. While it appears that the patients who received the SDoH screening had improved blood pressure control, the lack of effect on cholesterol or HbA1c could mean the time for data collection and analysis was too short to see measurable results and effects on these other clinical outcomes.

Joseph et al. [15] evaluated the effect of a closed-loop communitybased referral pathway in reducing social needs among Black men participating in a lifestyle change program to improve diabetes and cardiovascular health. The study analyzed both change in social needs and change in American Heart Association’s (AHA) Life’s Simple 7 (LS7) score during the intervention period. The intervention resulted in statistically significant reduction in social needs, but no discernable effect on health status as indicated by the LS7. The study’s results are important for determining whether social care coordination directly correlates with improved health outcomes.

Study participants were diverse in terms of education and socioeconomic status. More than half of the participants had at least one social need prior to intervention and the number with a social need reduced throughout the program. While social needs were addressed during the program, there was no direct association between social needs and health status as the change in social needs did not affect the LS7 score. The health score improved throughout the healthy lifestyle program regardless of the social needs being identified or addressed.

The study reveals the necessity of larger studies to evaluate community-integrated strategies to improve health and address social needs. There is no evidence of similar community-based participatory research approaches focused on LS7 in Black men. The population studied was extremely narrow and small as it only included 70 Black men who enrolled at a local health fair event. A total of 40 had at least one identified social need and 31 accepted a referral to the community resource hub, but only eight enrolled into services.

The combination of having a limited number of study participants and no control group limits understanding about the role social needs have on cardiovascular disease. It also limits any understanding of how of an intervention that involves social care coordination impacts health status. More research is needed to discern whether there are particular social needs that are more strongly associated with health indicators for specific chronic conditions. It is also important to evaluate when and how social needs screenings and referrals are incorporated into care delivery.

Conclusion

Healthcare regulatory entities such as Centers for Medicare and Medicaid Services (CMS) and the Joint Commission began requiring SDoH screening and referral programs to meet new quality and safety standards of care in 2023. The impetus for these new requirements was the role SDoH play in a patient’s ability to access equitable health care and manage health conditions. While it is common knowledge that social and behavioral factors contribute 80 to 90 percent of a person’s health status, the literature reviewed is insufficient to determine whether an intervention including screening and addressing SDoH in a healthcare setting results in improved health outcomes or health status for diabetes or hypertension.

Each of the three studies examined in this systematic review included interventions that combined healthy lifestyle programming, health education with care management and routine screening and referrals for SDoH. These studies were conducted in a limited period overlapping with the COVID-19 pandemic. The lack of statistically significant improvement in clinical health outcomes may indicate the interventions need to take place over a longer period to influence health status. None of these studies provided data showing whether an improvement or change in SDoH influenced health status; the studies only investigated correlations between screenings, education, and health outcomes. The evidence did not clearly demonstrate how closing the gap or addressing adverse SDoH affects health.

While healthcare providers can screen and refer for SDoH and should consider SDoH as they develop a treatment plan with a patient, they do not necessarily have the resources, ability, or capacity to address adverse SDoH during a visit or health program. Individual issues of food insecurity, transportation, housing, income, education and other SDoH factors cannot easily be addressed in a single visit or even several visits. To address SDoH, a community must have services and resources and providers must have knowledge about these resources to make appropriate and impactful referrals.

Incorporating a process for screening and addressing SDoH as part of a healthcare intervention is a new concept for healthcare providers. While regulatory entities have issued new standards for screening and addressing SDoH, they have not provided clear guidance or best practices for how healthcare organizations can effectively integrate an SDoH screening and referral program into a healthcare delivery model. Also, there are no known benchmarks or expectations for the extent to which a screening and referral intervention, even with other strategies, can improve health status and outcomes.

These three studies included in the final stage of the systematic review aim to assess whether screening for SDoH can improve social needs among specific patient populations. Future research should evaluate how SDoH screening and referral programs can address adverse social risks or needs. If research indicates that existing screening and referral programs cannot improve social risk factors, then more analysis is warranted to understand the barriers providers face in addressing SDoH. If research reveals that screening and referrals do improve social risks and needs, then researchers should study which specific health outcomes are directly impacted by improved social risk factors.

Limitations and Strengths

This review is limited by the inclusion criteria of hypertension and diabetes in the database search which may have reduced the number of articles applicable for the review. This is an indication of the need for a broader search to determine whether any health outcomes are associated with an intervention that includes SDoH screening for other diseases or conditions. A strength of the study was the evidence-based approach the researchers took to obtain, review, and critically analyze studies appropriate for the research question. Another strength of the study is how it informs the direction for future research in this burgeoning area of study.

Acknowledgements

The authors would like to acknowledge the TidalHealth library staff in helping with online web searches.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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