Care providers are using new tools to address social determinants of health
August 28, 2019
If you’re seeing your family doctor to treat a rash, would you mention you recently lost your job? Is your doctor likely to ask? Is it even relevant? The more work that’s done in Canada to reduce health inequalities, the more we know that social determinants of health – including income security – have an important influence on outcomes. Yet, care providers don’t have a standardized way to collect this type of data and treat their patients accordingly.
A project led by Dr. Andrew Pinto, a family physician and researcher in the Upstream Lab at the Centre for Urban Health Solutions of St. Michael’s Hospital in Toronto is aiming to change that.
Funded in part by the CIHR Primary and Integrated Health Care Network, the 75-member team of researchers, clinicians, patients and policy makers is working to develop an efficient and effective method of screening patients so that sociodemographic data, including income, can be easily integrated it into clinical workflow.
Their study is entitled SPARK: Screening for Poverty and Related social determinants and intervening to improve Knowledge of links to resources.
“It’s really understanding that people’s health is determined by lots of different factors and we need our health system to be able to intervene on some of these factors which, to date, we haven’t really thought about,” said Dr. Pinto. “We’re starting to think about a term like ‘socially informed care’, where you’re actually changing your care plan based on a person’s social circumstances.”
Building on prior work, which includes a pilot study in six Ontario clinics, the SPARK project is testing an automated patient-screening process. Questionnaires designed to sensitively determine income security and other social challenges are administered in a waiting room on Android tablets.
Answers are automatically fed into the patient’s electronic medical record (EMR), and a link of resources tailored to the patient’s specific set of circumstances is available to the physician, who can then print a customized information handout for the patient.
The cloud-based platform driving the process, called Ocean, is provided by CognisantMD, a Toronto-based company working to bridge gaps in healthcare through patient engagement solutions. Ocean simplifies the process of creating online forms and provides the integration piece to capture data and feed it to the EMR, ensuring it shows up where clinicians expect to see it and where it can be useful.
“It’s one thing to build a great poverty screening tool, but if clinicians need to think about using it every time, it’s a much harder change-management process,” said CognisantMD co-founder and president Jeff Kavanagh.
“But if you can script your kiosk (or tablet) in your waiting room to ask a few questions that will then trigger the full screen, that’s automation, and that’s the kind of thing that gets you from a neat pilot into something that is producing quality improvement at large scale.”
Dr. Pinto said tablets are a vast improvement over paper-based patient surveys. When data is collected on paper, someone has to enter it into the EMR, allowing room for error. Paper forms are considered less confidential, whereas electronic forms are seen as being more secure and are actually showing a higher response rate from patients. Perhaps the biggest benefit is that EMR integration means the answers are immediately available.
“It’s seamless. It’s secure. It’s more efficient. And, the information is actually available right when the provider is then meeting with the patient,” explained Dr. Pinto. “The way we’ve structured it, if a patient identifies they’re having social challenges, the EMR can suggest some pathways to the provider.”
For example, if a patient identifies they are having financial difficulty, the SPARK tool will present the treating physician with links to specific financial benefits they may be eligible for. The project team partnered with Prosper Canada, a national charity working to expand economic opportunity for Canadians living in poverty, to build the functionality.
Or, when a patient indicates they are having trouble paying for prescription medication, the screening platform will flag it in the EMR so the treating physician knows to prescribe a lower cost option or suggest an alternative therapy. If someone needs help filing their tax return, information on the nearest community agency will be provided as a link in the EMR, which the provider can print out and leave with the patient.
Patients in the Ontario pilot were followed for four months to determine the impact of identifying those at risk of poverty and intervening to help them gain income and better financial security. The goal is to show that screening ultimately improves health outcomes.
“We already know a lot about the relationship between income and health. This study is very much an intervention on income,” said Dr. Pinto. “What we’re working towards is a set of questions that is standardized across Canada.”
This fall, the SPARK team will be launching a Delphi study to gain consensus on what those standard poverty screening questions should be. A much larger inter-provincial study is slated to begin in 2020.
The Centre for Effective Practice (CEP), a not-for-profit organization at the University of Toronto’s Department of Family and Community Medicine, is another group working to identify and assist at-risk members of society at the primary care level.
In 2018, the centre received Ontario Trillium Foundation funding to conduct a pilot in four Ontario cities: London, Sudbury, Cambridge and Toronto. Its clinical tool, also supported by the CognisantMD Ocean platform, screens for poverty by asking questions like, “Do you ever have difficulty making ends meet at the end of the month?” or “Have you filed your taxes yet?”
Similar to the SPARK study, the CEP poverty tool generates a set of local supports and resources for physicians by linking to 211Ontario, a free helpline and online database of Ontario’s community and social services.
CEP director Lena Salach said the approach of using a screening tablet in the waiting room enabled patients to be engaged in a non-threatening way, and encouraged them to be more candid with their answers.
“There was a very safe environment because the provider wasn’t directly asking them the questions right at the provider-patient interaction,” she said, adding that the questionnaire was created at a Grade 6 reading and comprehension level and is designed to be user friendly.
Overall, the initial four-site pilot screened 4,517 patients and 12 percent were found to be at risk of poverty. Of those, 30 percent were provided with customized resources and referrals to community supports.
Though the centre has not received additional funding for the project to date, the form is available for download from the CEP website, along with an integration piece to support the Telus PS Suite EMR. This fall, the centre is looking to secure a grant to expand its work on poverty screening with a focus on implementation assistance and integration with other EMR platforms.
“We’re really about understanding what the care gaps are in primary care and working to close those gaps,” said Salach, noting that the goal is to help providers to understand the impact of living in poverty, how it correlates to chronic conditions like diabetes, asthma, arthritis, cancer, COPD and mental illness, and that there is something they can do to help.
“Awareness of that is still relatively low among providers,” she said. “They think it’s such a huge undertaking, but it’s actually not as difficult as one thinks.”
One area where screening for at-risk populations is growing is in nutrition. Heather Keller, research chair at the Schlegel-University of Waterloo Research Institute for Aging, developed a screening questionnaire that is now accepted as best practice worldwide.
The self-assessment tool is called SCREEN: Seniors in the Community Risk Evaluation for Eating and Nutrition and consists of 14 questions covering appetite, frequency of eating, motivation to cook, ability to shop and prepare food, weight changes, isolation and loneliness, chewing and swallowing, digestion and food restrictions due to health outcomes.
Originally created as a paper-based tool two decades ago, SCREEN has been gaining traction in recent years, in part due to the automation provided by the Ocean platform.
Instead of filling out paper questionnaires, patients are either presented with tablets in the waiting room or emailed a link which they can complete from home. Their answers are then integrated into their EMR.
“You don’t have recording errors. You don’t have concerns about a clinician having to do it during a clinic visit and wasting time,” said Keller. “You just see the result and go right from there to the next step around treatment and consultation.”
The idea for nutrition-screening was spawned when Keller was working as a dietitian in a chronic care and rehabilitation setting. She noticed that many seniors who came in after a fall were underweight and wondered if identifying nutrition problems early on could help with fall prevention as well as malnutrition, ultimately helping to keep people healthier as they age.
“I realized if we want to do anything to improve nutrition in older adults, we had to figure out how to measure it quickly and easily,” she said, adding that the screening tool was developed with clinical practice in mind.
Five family health teams in Northern Ontario recently took part in a study involving the SCREEN tool, which was administered on Ocean tablets. According to Keller, the seniors found it easy to use and reported that the information provided raised their awareness of nutrition risk and how to overcome it.
“The Ocean tablet made it much easier but we still have to work out the process of who’s going to hand the tablet to the senior, who’s going to give them the result, who’s going to give them the handout – those little process steps,” said Keller.
Whereas nutrition screening in older adults experienced a slow uptake, a similar approach to nutrition screening in preschoolers and toddlers was quicker to take hold.
The NutriSTEP nutrition screening program, led by dietitian researchers from the University of Guelph and the Public Health Sudbury & Districts, with input from Keller, provides a 17-item questionnaire for parents to fill out.
Similar to other screening initiatives, they receive a personalized handout with specific recommendations for their child and links to more resources. When integrated with the EMR, the primary-care practitioner gets access to a summary of results and a calculated risk score.
“It’s not just screening,” said Keller. “It’s an intervention in and of itself, because it raises people’s awareness that,‘Hey! I’m not eating as well as I should be’ or ‘I’m having some grocery shopping difficulties. Maybe I should think about that.’”