INTRODUCTION

Knowledge of a patient’s health-related social needs is essential to providing high-quality, affordable, and safe care1 and is important to understand factors contributing to exacerbations of illness and in developing discharge plans.2 We sought to characterize hospitalized patients’ health-related social needs and determine clinicians’ knowledge of their patients’ needs.

METHODS

This observational study was conducted at a large urban academic hospital. Between July 22, 2019, and February 28, 2020, we recruited adult patients admitted to general medical services. We excluded patients whose preferred language was not English and those disoriented to person, place, or time. Clinician participants included hospitalists, advanced practice providers, and residents providing care for enrolled patients.

We used the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) screening tool to identify patients’ social needs.3 This tool identifies unmet needs across five core domains: housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety. We also used supplemental AHC HRSN questions assessing financial strain, instrumental activities of daily living, social isolation, and disability.

Research coordinators conducted structured interviews on patients’ 2nd or 3rd hospital day using the AHC HRSN tool. After each patient completed the interview, research coordinators contacted the clinician primarily responsible for the patient’s care and asked how they thought the patient would have responded to the AHC HRSN tool.

Social needs were categorized as present or absent based on AHC HRSN criteria. We calculated the number and percentage of patients who reported a social need in each domain and compared patients’ needs to those identified by their clinicians.

RESULTS

One hundred thirty-seven of 218 (62.8%) available patients completed interviews; 102 (74.5%) clinician interviews were completed. Patients were a mean 58.1 ± 18.6 years of age, approximately half female (67/137; 48.9%), and majority white race (76/137; 55.5%). Seventy-two of 137 patients (52.6%) had a social worker involved in their care. Ninety (65.7%) patients reported one or more social needs (see Table 1). Across all domains, clinicians did not reliably identify patients’ social needs (see Table 2).

Table 1 Hospitalized Patients’ Health-Related Social Needs
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Table 2 Clinicians’ Knowledge of Hospitalized Patients’ Social Needs
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DISCUSSION

We found that many hospitalized patients have health-related social needs that were not identified by clinicians. One potential explanation for our findings is the traditional emphasis on biological approaches to disease rather than social needs in professional training. Clinicians might also have avoided obtaining information about health-related social needs due to a lack of confidence that they could adequately address patients’ social needs. A national survey of primary care physicians and pediatricians found that 85% felt it was important to address their patients’ social needs, but 80% were not confident in their capacity to address these needs.4 A hospital clinician may feel powerless to address needs like housing instability and financial strain and may feel that these complex problems are beyond the scope of the acute care system.

Although many determinants of health lie upstream of healthcare delivery and are rooted in the distribution of money and power at a population level,1 clinicians should adjust management decisions based on each patient’s needs. An understanding of a patient’s needs and preferences lies at the heart of shared-decision-making and is fundamental to creating a plan that will be acceptable to the patient. Weiner and colleagues have shown that physicians in ambulatory settings are prone to contextual error, defined as a failure to individualize care based on the patient’s economic situation, access to care, social support, and skills.5 Our findings suggest that hospital-based clinicians may similarly be prone to contextual error. Without knowledge of a patient’s social needs, a clinician may prescribe a medication the patient cannot afford or recommend self-care the patient cannot perform.

Our study was limited by its small sample size and was not adequately powered to compare knowledge of patients’ social needs across clinician categories. Although social workers were involved in the care for many patients, we did not evaluate the specific needs addressed by social workers in this study.

In conclusion, hospital-based clinicians are frequently unaware of their patients’ social needs. Future research should test interventions that help clinicians contextualize care plans and partner with other professionals in collaborative models to identify and address hospitalized patients’ social needs.