Social Determinants of Health: Learner-integrated Outreach, Screening, and Intervention in a Primary Care Clinic

Abstract

Introduction: Whether knowingly or unknowingly, clinical learners interact with factors in the social determinants of health model (SDoH) everyday; however, students often have tenuous grasps on identifying and managing these factors in clinical settings. These factors include education, employment, access to food and health care, neighborhoods and built environments, and social support networks. There is a growing recognition in primary care practices of the importance in educating students on treating patients' immediate health concerns and SDoH factors contributing to patients' presentations to improve health outcomes. At the Central Family Medicine (CFM) Clinic of the University of North Texas Health Science Center, clinical preceptors piloted the integration of SDoH resource navigation into clinical duties for students. Methods: In addition to traditional chart reviewing, students identified gaps in preventative screenings and SDoH needs. Patient encounters included administering the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) questionnaire to assess SDoH needs. After the encounter, students followed up with patients, linked patients to resources based on the questionnaire results, and involved social work for complex SDoH needs. Finally, descriptive data analysis was conducted on the questionnaire results to provide insight into the leading SDoH needs at the CFM clinic compared to that of the state's. Qualitative data analysis was conducted on student feedback testimonials to provide guidance on identifying areas of strengths and weaknesses to determine future goals for clinical learners. Results: Education levels in the clinic patient population were lower than that of the state's, with 23.6% of the patients having less than a high school degree, compared to 14.3% of Texas residents. Similarly, the unemployment level of the patient population is almost 3 times that of the state. 12.1% of the patient population experienced food insecurity, compared to 14% of Texas residents. Trends in clinical learner testimonials included active engagement in the process of addressing social needs, improved focused patient interviewing skills, and understanding the gravity of SDoH issues. Clinical learners found difficulty in conversing with SDoH resource representatives due to unfamiliarity with resource navigation and terminology. Conclusion: Based on the results from the PRAPARE questionnaire and student testimonials, there is a clear need for improving SDoH factors in the patient population, and for medical education to include SDoH training by involving students as a value-add to clinical operations in improving patients' health outcomes. With involvement in this work, students address the Accreditation Council for Graduate Medical Education competencies for family medicine in the domains of health promotion and wellness, advocacy, and physician role in healthcare systems. Future directions include recruiting clinical preceptors who promote training in using SDoH resources, a practice that is supported with financial incentives in recent policy, developing a toolkit for integration of students into preceptors' practices, and advocating for students to have clinical administrative time to work on patient care tasks that focus on improving SDoH.