Professional Medical Association Policy Statements on Social Health Assessments and Interventions

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Geoff Gusoff, MD; Caroline Fichtenberg, PhD;
Laura M Gottlieb, MD, MPH

Perm J 2018;22:18-092 [Full Citation]

https://doi.org/10.7812/TPP/18-092

E-pub: 10/22/2018

Abstract

Background: Evidence demonstrating the link between social and economic needs and health outcomes and a concurrent shift toward value-based payment models have incentivized health care delivery system leaders to explore social and economic risk-related screening and intervention programs. This study was designed to elucidate the ways in which professional medical associations (PMAs) encourage these activities in organizational policy statements and practice guidelines.
Methods: We extracted publicly available policy and position statements and clinical guidelines from 42 US PMAs that featured themes related to screening for or addressing patients’ social determinants or social needs in health care delivery settings.
Results: Among the 42 PMAs included in this study, 9 (21%) published 39 relevant statements. Fourteen of these statements referred to clinic-based social or economic health screening activities, 34 referred to clinical interventions to promote social or economic health, and 3 referred to strategies for financial support for these activities. Thirty-six of the 39 statements (92%) were published after 2008.
Discussion: PMAs are releasing public statements related to social needs screening and interventions in clinical settings with increasing frequency. Disciplines such as pediatrics, family medicine, and psychiatry are policy leaders in this area. Statements released by PMAs representing these disciplines include detailed information about social and economic needs screening and interventions that can be adopted by clinical care systems.
Conclusion: Findings in select medical disciplines indicate that social health assessments and interventions are gaining acceptance.

Introduction

An expanding literature explores ways in which social and economic risk factors contribute to persistent inequities in population health and well-being.^1-7 These findings are grounded in a body of work that demonstrates how race/ethnicity and class differences manifest in uneven access to and quality of education, employment, and wealth, which contributes to disparities in access to material goods such as housing and food; stress; and health behaviors such as smoking, physical activity, and nutrition.^8-14 As the literature that links upstream social and economic risk factors and downstream health inequities has expanded, the health care financing focus has shifted from rewarding volume to rewarding positive clinical outcomes.¹⁵ These developments have incentivized some health care system leaders to explore concrete ways to recognize and improve social and economic conditions as one part of a comprehensive strategy to improve health outcomes.¹⁶ In clinical settings, these innovations largely have focused on identifying and addressing patients’ basic material needs by strengthening bridges between medical and social service organizations.

Despite the evolving evidence demonstrating that targeted programs may improve well-being for people with socioeconomic barriers to health care,^16-19 there is little awareness of the extent to which screening for social and economic risks and related interventions actually has been adopted across the health care sector.^20,21 Existing patient, practitioner, or payer survey findings are limited by small numbers of respondents, restricted to particular medical disciplines, or focused on unique clinical settings.^22-29 Statements from professional medical associations (PMAs), which may reflect or elevate new professional practice standards, provide a unique gauge of the degree of engagement surrounding social health assessments and interventions. Although PMA policies do not always precede widespread clinical practice, they can pave the way for practice mainstreaming.^30-32 An advantage of using PMA statements to measure practice diffusion is that PMAs represent a wide range of medical disciplines, many of which have not been surveyed in other health services research. We reviewed policies and guideline statements from 42 PMAs with the goal of understanding ways in which social health assessments and interventions are endorsed across specialty groups.

Methods

Between January 1, 2018, and March 31, 2018, we reviewed the Web sites of the American Medical Association and all PMAs listed as members of the Council of Medical Specialty Societies. From the 42 sites, we extracted publicly available policies, position statements, and clinical guidelines that related to assessing for or intervening on patients’ social needs in health care settings. Articles were included if they referenced assessment or intervention activities for social determinants of health, social risk, social health or related topics such as food, housing, financial security/poverty, employment, or education/numeracy/literacy.

Exclusion criteria were applied if articles referenced “care management” or “extra-clinical services” without specifying social health assessments or medical and social/community service links to health care. Statements also were excluded when clinician advocacy or clinical education related to social health was described without reference to clinic-based screening or interventions. Articles referencing screening for or interventions related to intimate partner violence or substance abuse were excluded because these topics already have been examined by the US Preventive Services Task Force.^33-35 References to efforts to decrease discrimination in clinical care settings based on race/ethnicity, sexual orientation, or other patient characteristics were not included in this analysis. All extracted statements were reviewed by 2 authors (GG, LG) for relevance to the primary topic, and content was classified into screening, intervention, and financing categories; articles could be included in more than 1 category (Table 1). Other PMA publications such as press releases, letters to Congress, or affirmations of other PMA guidelines, even if publicly available, were not reviewed.

Results

Thirty-nine statements published by 9 of 42 PMAs (21%) met our inclusion criteria (Table 2). Of these statements, 21 (53%) were published by the American Academy of Pediatrics or the American Academy of Family Physicians. Fourteen statements referred to clinic-based social or economic health screening activities, 34 discussed clinical interventions to promote social or economic health, and 3 addressed strategies to finance the related activities. Of the 39 statements, 92% were published after 2008, 75% were published after 2012, and 50% were published after 2014.

The 14 statements promoting social health screening in clinical settings varied in content and specificity. Although all 14 statements encouraged practitioners to screen for social risk factors that could affect health, details regarding which social domains should be covered or how screening should be conducted were not uniformly included. For example, one American Academy of Family Physicians statement recommended, “Screening patients to identify patients’ socioeconomic challenges should also be incorporated into the practice.”³⁶ In contrast, 3 American Academy of Pediatrics statements^37-39 and 1 statement from the American College of Obstetricians and Gynecologists⁴⁰ referred both to specific screening tools (eg, a specific food security screening tool) and screening data storage/tracking approaches (eg, electronic health record-based tracking). Most PMA statements referred to screening generally for a range of social needs (eg, housing, nutrition, etc), whereas several statements referenced only domain-specific screening (eg, for human trafficking⁴¹ or food security³⁸) or encouraged screening in specific populations such as immigrant children.³⁹

Most PMA statements featured text that encouraged practitioners to assess and also intervene when social needs were identified. Intervention recommendations included making referrals, building stronger partnerships with social service providers, and providing social services within clinical settings. These recommendations varied substantially in terms of content and specificity; 35% of PMA statements provided guidance such as encouraging coordination with certain types of service providers such as housing or transportation organizations, referring to specific social service programs (eg, Women, Infants and Children or the Supplemental Nutrition Assistance Program) or promoting colocation of services at the clinic site such as medical-legal partnerships.^37,39,42 The remaining statements made general recommendations such as “partner with community resources.”⁴³ Among the statements that recommended interventions, 44% focused on subpopulations such as patients who were homeless or elderly or children with complex medical needs. Three statements included recommendations for social intervention funding strategies,^44-46 but only the American College of Physicians recommended a specific source that called for managed care organizations to include the costs of “specialized services” such as transportation or social service coordination in capitation rates.⁴⁴

Discussion

We searched 42 PMA Web sites for publicly available policy statements and clinical guidelines and found 39 statements published in 2002 or later that were related to social needs screening and interventions in clinical settings. This work, which explores the extent to which PMAs recommend social needs assessment and interventions, complements other efforts to examine the prevalence of social needs assessments and interventions across health care settings.^23-29 

As measured by their organizational policy and practice statements, pediatrics, family medicine, and psychiatry PMAs have been pioneers in this area. The organizations’ statements included details about which social domains to include in screening, interventions that can accompany screening, and, to a lesser extent, ways to finance those programs. Although it has not been established that PMA policy statements or clinical guidelines are ideal indicators of either current or future practice norms, our findings suggest that social health assessments and interventions are increasingly part of the PMA dialogue.

Few specialty associations include social health assessment or intervention recommendations in their public statements. Exceptions include the American College of Obstetricians and Gynecologists and the American College of Cardiology. Future work exploring the implementation and dissemination of social needs assessments and related interventions could focus on discipline-specific opportunities and barriers to assessing and addressing social needs (including available workforce resources, quality measures, and payment models). New uniform value-based payments and integrated care delivery models may help reduce discrepancies in social needs activities across disciplines.

This study has several limitations. First, we limited our study sample to the American Medical Association and the 41 PMA members of the Council of Medical Specialty Societies. Although there are other types of medical professional organizations such as the National Academy of Medicine and the Institute for Healthcare Improvement and organizations representing nonphysician practitioners such as nurses and social workers, we could not locate a representative list. Future work might examine policy statements from other professional health care organizations to reflect a wider range of practitioners. Also, there are important differences in how PMAs develop, format, and present public statements. Although PMA statements may reflect current or evolving practice norms, policy statements and clinical guidelines often are developed by small groups of experts primarily on the basis of members’ knowledge or interest in a particular area. Some statements are formatted as short declarations whereas others are extensive reports; some PMAs routinely make their statements publicly available and others rarely release their statements to the public. In our study, we found that PMAs offering the most publicly available content generally were more likely to produce social health-related statements; these statements often were quite detailed. At least 4 PMAs limited the number of publicly available statements on their Web sites, although other statements may have been accessible behind member-only firewalls. These differences in statement development and availability limited our ability to fully understand the degree to which PMA statements reflect practice. Finally, in some cases, PMA statements were reendorsements of earlier publications. These reendorsements appeared relatively uncommon, however, which suggests that the number of social health-related statements in the PMA literature is increasing.

Conclusion

We found a wide range of published statements from PMAs related to social health assessments and interventions. A small subset of organizations representing professional medical specialties including the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Psychiatric Association published the majority of these statements. Since our original search was completed, a 2018 statement from the American College of Physicians that was consistent with others included in this review recommended that all health professionals “should be knowledgeable about screening and identifying [social determinants of health] and approaches to treating patients whose health is affected by social determinants throughout their training and medical career.”⁴⁷ The number and content of the PMA statements identified in this study support other health services research^13,48,49 indicating that social health assessments and interventions are gaining acceptance in select medical disciplines.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Author Contributions

Geoff Gusoff, MD, led the professional medical association review and drafted the initial manuscript. Laura M Gottlieb, MD, MPH, conceptualized, helped write, and edited the manuscript. Caroline Fichtenberg, PhD, helped conceptualize and edit the manuscript.

Acknowledgments

The Robert Wood Johnson Foundation, Princeton, NJ, supported Laura M Gottlieb, MD, MPH, and Caroline Fichtenberg, PhD, in their work on this study. Geoff Gusoff, MD, worked on the project while interning at the Robert Graham Center, Washington, DC. We appreciate the contributions of Graham Center staff toward revising the paper concept and study design.

Brenda Moss Feinberg, ELS, provided editorial assistance.

How to Cite this Article

Gusoff G, Fichtenberg C, Gottlieb LM. Professional medical association policy statements on social health assessments and interventions. Perm J 2018;22:18-092. DOI: https://doi.org/10.7812/TPP/18-092

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Keywords: food security, health policy, social determinants of health, social interventions, social needs screening