Post-pandemic realities set in for screening patients’ social needs

The past three years of the COVID-19 pandemic forced many healthcare leaders to confront disparities in care as part of a broader rethinking of how to continue delivering it amid a public health emergency.

From job losses and financial uncertainty in the early months of 2020 to the new challenges of inflation and its strain on consumers, many health systems and medical groups put renewed focus on programs to screen for patients’ social determinants of health (SDoH) or health-related social needs (HRSNs).

Still, the dual pressures of maintaining public health safety measures and enough health workers amid a challenge labor market were enough to stop several organizations from pursuing other initiatives.

A Feb. 28, 2023, MGMA Stat poll finds that almost half (49%) of medical groups screen for patients’ social determinants of health, while 44% do not and 7% of respondents were unsure. The poll had 432 applicable responses.

These findings show little change from a similar MGMA poll from April 2, 2019, which found just more than half (52%) of groups screened for SDoH, while more than 1 in 3 (36%) did not and 12% responded “unsure.”

In the latest poll, three major social needs stood out as the most commonly screened:

• 81% reported screening for housing insecurity/needs.
• 76% said they screen patients for food insecurity.
• 3 out of 4 (75%) reported screening for transportation needs.
• Less than half (44%) noted they screen for literacy needs.
• About 3 in 10 respondents noted some other form of screening, such as abuse; safe or supportive relationships; childcare and/or baby supplies; joblessness; prescription assistance; heating/utility assistance; and school/education needs.

Among medical group leaders who were unsure about their SDoH efforts, a majority (73%) noted that their organization refers patients to community resources to help with needs such as food, housing and more.

New research into social needs

In April 2020, Humana and MGMA released our first joint research study report on the topic, Painting a Bigger Picture of Patient Well-Being, which described the development of SDoH screening tools and building connections with nonclinical community resources to help patients address issues that influence their health outcomes.

Later this month, MGMA and Humana are set to release a new study building on those findings with new research on how the views of healthcare leaders have been shaped by the COVID-19 pandemic, as well as how opportunities and challenges in screening for HRSNs have evolved amid the ongoing shift to value-based care and labor market issues affecting staffing in provider organizations.

Stay tuned

Watch the MGMA Insights newsletter at the end of this month for the new study, and MGMA members will be able to access more information on patient-centered programs in the April issue of MGMA Connection magazine, arriving online and in member mailboxes about one month from now.

Additional MGMA resources

• "Addressing health disparities: Using the 5 As to integrate social care into healthcare" — This MGMA Connection magazine article explores the framework of integration activities to help nurses, physicians and others to address social risks and help improve health outcomes in tandem with social workers.
• "Social determinants of health in an ACO for better population health" — Discover common barriers for SDoH programs and results from implementation at Massachusetts General Hospital in Boston.

New resources for SDoH

The Office of the National Coordinator (ONC) for Health Information Technology recently released a Social Determinants of Health Information Exchange Toolkit (PDF) that details the foundational elements needed for the exchange of SDoH information:



“The Foundational Elements inform each other, and governance intersects across each of them,” according to a blog post by ONC staffers Mark Knee and Meley Gebresellassie. The toolkit describes these elemental areas as follows:

• Community readiness and stewardship: Exploring the existing landscape in the geographic area and/or population of focus, assessing the capacity and willingness of the community to participate, and developing stakeholders’ shared rights and responsibilities through the process of co-design, evaluation, and decision-making.
• Mission and purpose: The intention of an initiative, ideally explicitly stated, that addresses the various value propositions of stakeholder groups, as well as the vision, scope of services, and expected benefits.
• Values and principles: Standards for establishing a framework for action, including ethical decision-making in pursuit of health equity.
• Policy: Consideration of federal, state, and local policy levers to advance the ability to collect, share, and use standardized SDoH data, as well as collaboration and alignment with other relevant efforts in the community, region, and/or state for collective impact and improved outcomes.
• Legal: Establishing the framework of processes and operations, along with rights and obligations, to support data use and sharing and to support compliance with federal, state, local, and tribal laws.
• Measurement and evaluation: Monitoring and evaluation of performance metrics, individual and population outcomes, program effectiveness, and quality management and improvement. 
• Financing: Funding opportunities, sources, and plans for investments, ongoing costs, opportunities for blended approaches, and incentives for community adoption and use. 
• Implementation services: Inclusive of technical services (e.g., defining requirements, standards specifications, and integration with existing infrastructure and services) and programmatic services (e.g., defining use cases, workflow design/redesign), as well as support for adoption and utilization by individuals and the community.
• Technical infrastructure and data standards: Alignment of hardware, software, data, processes, and standards to enable scalable and interoperable data and IT systems.
• User support and learning network: User support and learning network activities include assessment of community challenges and needs, education, communication, training, technical assistance, peer-to-peer learning, and identification of promising practices and lessons learned.
• Governance: Decision-making processes and groups, including as relates to institutional, administrative, and data governance.

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