Social Determinants of Health: Opportunity for Occupational Therapy

SDOH Efforts Require a Systems Approach

Occupational therapy practitioners address a person’s ability to perform daily occupations at work, in the home, in their environment, and in their community. To work toward addressing SDOH, occupational therapy practitioners must often approach two different needs: (1) the social needs of individual clients and (2) the structural challenges that affect the ability to meet these social needs. Addressing a social need, or needs, requires collaboration. For example, an occupational therapy practitioner may screen a client to identify food insecurity yet need to collaborate with other team members and organizations to truly meet this need. Occupational therapy practitioners already understand the importance of community. Their skills and knowledge make them ideal agents to collaborate with community-based organizations (CBOs) to meet social needs. Another collaboration that is important for SDOH is that between occupational therapy and public health. In public health, there is a shared understanding that behavioral and environmental interventions are highly dependent on people’s and communities’ level of readiness for change and implementation. Both professions recognize that people may encounter risk factors and adverse exposures in multiple domains that need to be taken into consideration when designing interventions. Occupational therapy practitioners working in the SDOH arena need a strong understanding of public health and its varying systems to truly address the structural components of these interventions. Looking to public health can help ground occupational therapy practitioners in the context needed to influence health.

Collaboration between professions and partners is also needed to address the current siloed approach to health care delivery, which limits impact on health disparities. One potential framework that can be used is the National Institute on Minority Health and Health Disparities (NIMHD) research framework, a multilevel, multidomain model that depicts a wide array of health determinants (Alvidrez et al., 2019). This framework takes into consideration the domains of influence through the life course (biological, behavioral, physical/built environment, sociocultural environment, health care system, and health outcomes) and the levels of influence (individual, interpersonal, community, and societal). In addition, the framework focuses on health disparities and specifies that health outcomes can span multiple levels and reflect aggregate outcomes. The adoption of a framework such as the NIMHD one provides a potential for collaboration and the development of research knowledge. With this type of approach, occupational therapy practitioners can better address the cumulative or interactive effects of multiple SDOH.

SDOH in Practice

Social needs and SDOH have always existed, and in many communities CBOs have long provided services. Health systems often have a preferred list of CBOs to which they refer clients to support social needs. However, many of these efforts continue to be disconnected and lack a sustainable structure. To truly begin to affect SDOH, health care and social care need more robust connection and collaboration (National Academies of Sciences, Engineering, and Medicine, 2019). In January 2021, the Centers for Medicare & Medicaid Services (CMS) issued a press release regarding the role of SDOH for Medicaid and Children’s Health Insurance Programs that identified opportunities for growing programs to support social needs (CMS, 2021). The press release specifically called attention to support for programs related to housing, transportation, meal delivery, and care coordination. Home accessibility was explicitly recognized, providing a clear role for occupational therapy practitioners in SDOH efforts. This press release signified an evolving support for addressing social needs and potential reimbursement for these services. In 2022, new guidance related to social needs screening was released. In August 2022, CMS released a fact sheet stating that

[A] Screening for Social Drivers of Health measure and Screen Positive Rate for Social Drivers of Health measure beginning with voluntary reporting in the [Calendar Year (CY)] 2023 reporting period and mandatory reporting beginning with the CY 2024 reporting period/[Fiscal Year] 2026 payment determination [will be implemented]. (CMS, 2022)

These screening requirements focus on hospital inpatient quality reporting programs. The Joint Commission (2022) required organizations to screen for health-related social needs and provide resources to clients who screen positive, effective January 2023. The Biden–Harris Administration identified the need to incentivize payers and providers to screen for food insecurity and other SDOH (White House, 2022). None of these provided guidance on who should screen or what screening tool to use, leaving a lot of opportunity for diverse interpretation and implementation. In January 2023, the CDC (2022a) released a Notice of Funding Opportunity that identified the need for bidirectional referrals for social needs, recognizing the need to share data around social needs referrals between organizations. In addition, CMS (2023) provided additional guidance to Medicaid directors on payment for social care through 1,115 waivers in lieu of services in January 2023. This guidance called for payment for social care to be cost effective and medically appropriate, recognizing social needs as health-related social needs (HRSNs). Although guidance continues to become more specific, current HRSNs focus on nutrition and housing. The reality is that, with support from policy, social care and health care are becoming a more connected and integrated system.

Social Needs Screening Tools

As the health care system continues to shift from volume-to value-based payment, an increased recognition of the impact of SDOH on health care has been brought to the forefront (Adler et al., 2016; Krause et al., 2021 ; Porter & Lee, 2016). Through this shift, it is anticipated that public health and health care professionals will be able to do more for the prevention of disease, increased quality of life, and access to critical social care services. One solution that has emerged in many regions of the United States has been an SDOH ecosystem in which existing and evolving resources are connected to ensure social needs are met. Much of the evolvement is based on efforts to connect health care and social care, leading to evolving partnerships and collaborations. In some states, these ecosystems are emerging in the form of community information exchanges that provide infrastructure to connect health care and social care data as well as generate data to tell a more informed story around SDOH. A community information exchange is “a community-led ecosystem comprised of multidisciplinary network partners who use a shared language, resource database, and integrated technology platforms to deliver enhanced community care planning” (Grounds et al., 2022, p. 7). Through this infrastructure, there is the opportunity for occupational therapy practitioners to collaborate and take a holistic approach toward supporting the health and well-being of community members.

One important activity being tackled by SDOH ecosystems is screening for social needs. Health systems have begun to engage in social needs screening, ranging from screening only for high-risk individuals to screening for all clients. A wide range of screening tools are available, and health system professionals choose what tools and technology they find most helpful in meeting the needs in their specific communities. Some screening tools are available in electronic health records (EHRs), and others are included in social care referral platforms. CMS recently released guidance on which screening tools meet their requirements, recommending tools that focus on housing and transportation needs. Two major tools that meet CMS requirements are the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) and the Accountable Health Communities Health–Related Social Needs Screening Tool (AHC–HRSN). PRAPARE is available via open source and has been translated into multiple languages along with undergoing psychometric testing. The AHC–HRSN is also available via open source. In some settings, social needs screeners are built into EHRs prepopulated for clinical use. For guidance on screening tools, the Social Interventions Research and Evaluation Network (2019) published a Social Needs Screening Tool Comparison Table that can be helpful when choosing a social needs screening tool (Henrikson et al., 2019).

Although there currently is an increased focus on screening, multiple challenges and opportunities exist. Not all screening tools are standardized or validated, and multiple tools exist. Many of the screening tools have not been mapped to electronic data standards. Some tools are also lengthier than others. One study found that clinicians ask clients about SDOH but lack clear and consistent strategies to document the information, so it often does not end up in the client record (Vale & Perkins, 2022). Workflows, timing, and who completes the screenings are all important considerations to address these issues. Staffing and the resources required to address a social need can also be difficult and time consuming, especially for more challenging social needs, such as housing instability.

Social Care Referral Platforms

In addition to screening, social care referral platforms have proliferated in the health care market. These platforms allow health care teams increased access to community resources. The platforms offer a variety of different services, including screening and the opportunity to make closed-loop referrals, which allow health care providers to send a social needs referral electronically to a CBO. The referral is then reviewed, and the outcome of the referral is reported back to the sender. This not only ensures that social needs are addressed but also generate data on social needs. Many of these platforms are new and evolving technology. Unlike other health care diagnoses, social needs do not have consistent data standards. The Office of the National Coordinator for Health Information Technology (2022) includes social needs in the U.S. Core Data for Interoperability, yet not all platforms are using these standards. Moreover, many of these systems are separate from EHRs, forcing health care teams to log in to a different system to make social needs referrals. Data standards for social care, known as International Classification of Disease (ICD; World Health Organization, 2015) Z codes, are also evolving. CMS recognizes codes Z55 through Z65, and new ones have been developed by the Gravity Project and were released in 2022 (Gravity Project, 2022). Despite being available ICD codes, reimbursement for Z codes has not proliferated. Issues with clinical workflows and data standards present considerable challenges with integrating social care referral platforms into health care organizations. In addition, connecting health care and social care requires that trust among community partners be built, and technology is only part of the solution (Cartier et al., 2020, 2023).

Opportunity for Collaboration

To address SDOH, cross-sector partnerships that involve stakeholders and champions from multiple settings are being created. As mentioned, there are partners, and then there are the activities of the partnerships within the SDOH ecosystem. Like partnership models, they vary on the basis of the partners involved and the local community needs and infrastructure. According to the Office of the National Coordinator for Health Information Technology (2020), considerations for this ecosystem include community readiness, financing, technical tools, data standards, legal resources and governance, policy, and evaluation. Understanding the current climate and activities of an SDOH ecosystem is critical before any discussions on the importance of collaboration take place.

The time and resources needed to address SDOH continue to be areas of challenge. Clinical staff may feel overburdened or lack the time to adequately address clients’ needs. There may be limited staff to address social needs, restricting the number of individuals who can be screened and connected with the appropriate social care resources (Nohria et al., 2022). In addition, some clients may prefer not to report on social needs, or to not have their social care data collected in an EHR. This is a common situation among members of marginalized and vulnerable communities (Galvan et al., 2021). The social needs of these individuals must be acknowledged, and workflows must allow a “no wrong door” approach to social care. Some organizations have initiated self-screening that has led to increased success (Moen et al., 2020). Additional challenges with screening are that, once a need has been identified, teams must ensure an appropriate resource is matched to assist the client, and documentation must be added to the client record as their status and needs change. In certain situations, it is likely that social care resources are limited in a community because of limited staff, policies, inadequate funding, or lack of a program. Despite the challenges, many opportunities to address clients’ social conditions exist. Collaboration across partners, sectors, and teams is critical to ensure an ecosystem can support clients, clinicians, and systems that are engaging in activities such as social needs screening.

Implications for Occupational Therapy Practice

The world of SDOH is evolving and open to opportunity and discovery. The specific role occupational therapy practitioners will play has yet to be determined. However, in the unknown there is an opportunity to find ways to support the growing need to address SDOH. Community-based programs that support unique care models involving cross-sector partnerships are emerging and offer potential roles for occupational therapy practitioners, including Pathways Hubs, Project CAPABLE (Community Aging in Place— Advancing Better Living for Elders), medical respite for the homeless, and chronic-care hubs. Several of these community-based programs use community health worker models as part of a team to support social care. These community health worker models vary depending on the health issue they are addressing, but they share similarities in that they can serve as a bridge between stakeholders. Reimbursement varies, yet managed care organizations, accountable-care organizations, the CDC, and CMS are all funding different initiatives in SDOH. Managed care organizations are now required to support social care and can be a great place to explore innovative programs that might offer occupational therapy practitioners opportunities to get involved.

In clinical environments, social needs screening is now becoming a requirement. Occupational therapy practitioners can find out what their health system is doing for screening and get involved. In addition, many health care and community organizations are starting to use social care referral platforms. Occupational therapy practitioners can identify social needs and make social care referrals. In some communities, ecosystems for SDOH are being built. In this situation, occupational therapy practitioners can play many roles by being a referral site, if they offer an important social program; screening for social needs; making referrals; and supporting client navigation of the various systems. Some states or cities are building community information exchanges, which are meant to be a centralized repository for resources and referrals.

Another role for occupational therapy practitioners is advocacy, as occupational therapy practitioners have a role in supporting the well-being of their clients. This calls on the profession to address social needs and ascertain ways to address the structural barriers that cause SDOH. Advocacy often sounds like a complex task, yet the opportunity to advocate occurs daily. There are three types of advocacies: (1) self-advocacy, (2) individual advocacy, and (3) systems advocacy (West Virginia University Center for Excellence in Disabilities, 2022). These types of advocacies occur at different levels, but they all aim to promote the interest or cause of someone or a group of people. Ensuring that clients have their social needs screened and met is a critical form of advocacy that can truly make an impact. With regard to structural issues, advocacy takes on additional complexity. Advocacy in these spaces requires cultural humility along with an awareness of one’s power and privilege dynamic. Entering this space with others in the community to ensure that the voices of all are articulated, and the lived expertise of those experiencing disparities and inequities are valued, is critical. In some sense, knowledge is power, and we hope that reading this column opens the opportunity to advocate to ensure that clients gain access to needed resources. Despite the challenges, many assets exist in communities. The charge to address SDOH will require many people, from diverse backgrounds, experiences, and organizations, including expertise from the field of occupational therapy.