Social determinants, or the daily conditions in which we live, work, and play, contribute to an estimated 70-80% of health outcomes. Health systems are increasingly measuring how social factors influence the health outcomes of their patient populations. Currently, federal and standard setting bodies have established screening for social needs as an effective way to identify patients’ social determinants (e.g. food insecurity, housing instability). Collecting this information helps health systems measure the impact of social factors on their patient health outcomes. Additionally, it allows them to appropriately dedicate resources to address those needs. Ultimately the goal is to improve health outcomes for all, including those underserved. Standardized screening is new to the rehabilitation setting. This Applied LeaRRning case describes how our team conducted implementation mapping to identify determinants underlying uptake of standardized screening for social needs at Spaulding Rehab Boston and to co-create solutions with stakeholders. The goals was ultimately to improve reach to all patients. 

Our theoretical framing was informed by the Practical, Robust Implementation and Sustainability Model (PRISM) framework and the National Academies of Science 5 Activities to Integrate Social Care model. Our process was guided by Implementation Mapping, which takes a co-creation approach involving stakeholders throughout all phases of a project, from defining the problem to co-creating effective and sustainable solutions. We first used electronic health record data to retrospectively assess variation in screening adoption rates by the facility (i.e. Boston and Cape Cod), the unit (e.g., stroke unit), and the type of frontline implementer (i.e., nursing, social work). We also examined the proportion of patients screened by diagnosis and demographic characteristics. From this descriptive assessment, we did not find notable variation in screening by patient diagnosis or demographic characteristics. We found most of the variability at the facility level (Boston 16% and Cape Cod 86%) and among frontline implementers. We thus decided to focus qualitative interviews on the Boston facility and the primary frontline implementers, case managers. 

Through our interviews we found that case managers saw the new social needs screening practice as distinct from their prior practice. It systematically addressed a broad set of social needs impacting long term health, rather than targeted barriers to discharge from rehab. As a part of addressing these broader social needs, case managers emphasized that disability access was of utmost importance. First, case managers expressed that the standardized social screening questions were not accessible for patients with cognitive and communication difficulties, thus impacting reach. Additionally, in providing referrals to identified needs, case managers were not fully equipped with community resources addressing social needs in accessible ways, such as housing programs with wheel-chair accessible options, or transportation programs that offer alternatives to online portals for patients with cognitive and communication disabilities. 

Conclusion: Social needs screening must reach all patients. We identified gaps impacting the potential reach of a social needs screening practice in inpatient rehabilitation. To advance these gaps related to equity, rehabilitation organizations, clinicians, and researchers must consider issues related to accessibility so that patients with cognitive, communication, visual, upper extremity and mobility disabilities can benefit from these services.