Toward optimizing social drivers of health screenings in prenatal care: Healthcare professional perspectives

Abstract

Introduction

There is increased drive, including government‐based mandates, to perform social drivers of health (SDoH) screenings across healthcare settings, without robust evidence to inform the process. Here, we aimed to understand perspectives of healthcare professionals (HCPs) around conducting SDoH screenings in a unique healthcare interaction, the prenatal care setting.

Methods

We conducted a qualitative study with HCPs from February 20, 2023 to May 31, 2023 until thematic saturation was reached. Semi‐structured interview guides were developed using the Consolidated Framework for Implementation Research (CFIR 2.0). Interview domains included (1) HCPs’ willingness to conduct screenings, (2) preferences on how to conduct screenings, (3) current and preferred referral processes based on screening results, and (4) hopes for the future.

Results

A total of 15 HCPs were included. We found that most HCPs were willing to conduct SDoH screenings and understood their importance in patient care. HCPs also expressed concerns around the lack of resources to effectively conduct the screenings, noting lack of time, training, reimbursement, and a robust knowledge of the resource landscape to support patients who screened positive. It often fell on HCPs to take on additional work and emotional burden to support their patients.

Conclusion

While HCPs feel positive about SDoH screenings in the prenatal care setting, it is important that they receive adequate support to conduct the screenings effectively. Emerging recommendations from this work include: maintain an up‐to‐date database of local resources and designate an individual who is well‐versed in the resource landscape to support patients who screen positive, train all HCPs on SDoH and screening best practices, and implement incentives to support and acknowledge HCPs for their work.

1. INTRODUCTION

Rising recognition of the impact of social drivers of health (SDoH) on patient outcomes has increased healthcare system SDoH screenings for patients. This is amplified by mandates from the Center for Medicaid and Medicare Services (CMS) for screening admitted patients [1], as well as through incorporation of screenings by individual state‐based Maternity Medicaid plans, including Pennsylvania's Maternity Care Bundle [2], and recommendations from American College of Obstetricians and Gynecologists (ACOG) [3].

Maternity care is a critical space for SDoH screening and referrals, as adverse SDoH can drive poor health outcomes for pregnant patients and newborns. SDoH such as poor‐quality built environments and psychological stress are associated with pre‐term birth and low birthweights, particularly for Black patients [4]. While healthcare systems are mandated to introduce SDoH screenings, the implementation of screening generally falls on individual healthcare practices and healthcare professionals (HCPs). Evidence remains limited as to best practices and tools for screening of SDoH needs, with a paucity of data around patient and HCP perspectives on screening. Prenatal care settings face unique difficulties given the team‐based approach to prenatal care and the lack of long‐term follow‐up after the pregnancy episode, but also unique opportunities due to the frequency of patient visits.

Prior work from our team elucidated patient perspectives on SDoH screening, giving concrete recommendations for this process [5]. Here we focus on the HCP perspective, including: (1) HCPs’ willingness to conduct screenings, (2) preferences on how to conduct screenings, (3) current and preferred referral processes based on screening results, and (4) hopes for the future.

2. MATERIALS AND METHODS

We conducted a two‐arm qualitative study enrolling English‐speaking patients and HCPs across five prenatal care sites at Penn Medicine, a large urban academic health system with multiple delivery hospitals. Prenatal care sites varied in population demographics and in stage of SDoH screening implementation. While all sites conducted some form of screening to learn about patient needs, only one site had implemented a structured process in line with CMS mandates. The Institutional Review Board (IRB) at the University of Pennsylvania approved both arms of the study in December 2022.

Eligible HCPs were full‐time staff members sampled to provide a representative range of roles and time in their position. HCPs were recruited into the study via e‐mail; 36 HCPs were contacted.

Semi‐structured interview guides were developed using the Consolidated Framework for Implementation Research (CFIR 2.0) (Table 1). Interview domains included (1) willingness to conduct screenings, (2) preferences on how to conduct screenings, (3) referral processes based on screening results, and (4) hopes for the future. These domains correspond to the group's work focused on patient perspectives. Informed consent was obtained verbally for all participants. Interviews were conducted through Zoom video calls from February 22, 2023 to May 31, 2023 by team members with no role in clinical care. Thematic saturation was determined when no new themes were identified for the most recent three interviews conducted. HCPs were compensated with a $25 gift card upon interview completion.

TABLE 1.

Key examples of interview questions.

Domain	Questions	CFIR construct
Willingness toward screening/resource referrals	In your role, have you ever had discussions with patients about their personal experiences with SDoH needs? If yes, how did you respond or what did you provide the patient? How did you feel during the process?	Inner setting domain: Assessing needs
	Of the SDoH categories, which do you feel most confident discussing with patients? Which do you feel least?	Individuals domain: Motivation
Willingness toward screening	What are your thoughts on the culture at your institution around physician–patient relationship? What do you see as the biggest obstacles to collecting SDoH data from patients?	Inner setting domain: Assessing context
Screening preferences	Do you have a preference between in‐person or asynchronous questionnaires?	Implementation process domain: Assessing needs—innovation deliverers
	Which hospital role do you think the patient would feel most comfortable sharing SDoH information with? Which role do you feel is best positioned?	Inner setting domain: Relational connections, work infrastructure
Screening preferences	What type of patient follow‐up do you think is feasible for the individual who is tasked with conducting SDoH screenings? Where do you think that an SDoH screening would best fit into the care workflow?	Implementation process domain: Assessing needs—innovation deliverers
Willingness toward screening	Would you feel confident if this role—screening patients for SDoH needs—was assigned to you? What would you need to feel confident?	Inner setting domain: Capability, available resources
Resource referrals	What type of patient follow‐up do you think is feasible for the individual who is tasked with conducting SDoH screenings? Inquiries as to whether the patient accessed the resources that were provided Patient reminders to utilize the resources they were connected to Follow‐up questions on how the resources helped and if they were supportive enough	Implementation process domain: Assessing needs—innovation deliverers
Hopes and concerns	What is your biggest concern with implementing SDoH screenings into the prenatal care trajectory?	Individual's domain: Motivation
	What is your biggest hope or excitement with implementing SDoH screenings into the prenatal care trajectory?	Individual's domain: Motivation

Abbreviations: CFIR, Consolidated Framework for Implementation Research; SDoH, social drivers of health.

Interviews were transcribed by ADA Translations, and transcripts were uploaded into NVivo 14.0. The study team met monthly during the interview period to review transcripts, determine thematic saturation, and develop a codebook reflecting the research questions. All interviews were double coded by two members of the research team using inductive and a priori themes (CFIR constructs). Any discrepancies in coding were discussed by both coders until consensus was reached, and decisions were reviewed by the larger research team. Theme sheets were created and reviewed by all researchers. Representative quotes from individual participants were selected by the project manager to match identified themes. Analysis was completed in June 2024.

3. RESULTS

A total of 15 HCPs were enrolled in the study (Table 2). HCP roles reflected the wide range of individuals in the Obstetric (OB) clinic representing different levels of administrative management, frequency of patient interaction, time in role, and experience working with social needs. While the time in the role was not formally collected, the range spanned from 2 to over 30 years across the cohort.

TABLE 2.

Healthcare professional demographics.

	n(%)
Location
Helen O. Dickens Center for Women's Health	3 (20)
Ludmir Center for Women's Health	4 (26.7)
Penn Ob/Gyn Associates	2 (13.3)
Penn Family Medicine	2 (13.3)
Pennsylvania Hospital Faculty Practices	4 (26.7)
Role
Physician (OB trainee, OB resident, MFM resident, OB attending)	4 (26.7)
Social worker	2 (13.3)
Care coordinator	1 (6.7)
Nurse practitioner	2 (13.3)
Outpatient administrator	1 (6.7)
Nurse	2 (13.3)
Midwife	2 (13.3)
Medical assistant	1 (6.7)

Abbreviations: OB, Obstetric; MFM, maternal‐fetal medicine.

3.1. HCP willingness to conduct screenings

When asked which role(s) should be responsible for conducting screenings, HCPs based their answers on factors such as who would be most able to tailor patient care, who had the better relationship and trust with the patient, and who had the best understanding of the resource referral landscape. While social workers were the most identified role for being best positioned to act on positive screens, most HCPs said that they felt that it was their own responsibility to talk to their patients about their needs in order to provide the best care. One physician trainee explained:

I think we should play a role in this, and I think that, patients, they entrust us with their care. And I think there is a little bit of that inherent trust that your doctor is looking out with your well‐being and what's best for you… I think it is actually very important for us to ask.

Many HCPs felt comfortable talking to patients about their social needs, noting feeling grateful to patients for their willingness to share personal information and an opportunity to provide better care by understanding patients’ circumstances. However, one physician described the emotional drain associated with screenings:

It's…a balance between being in the moment and ensuring that I'm taking care of that patient, but also not trying to actually be the person who takes every burden onto myself.

A nurse practitioner described not having enough resources, training, or reimbursement to effectively conduct screenings:

I just don't know what's out there to help these patients…I feel really helpless in those situations in helping my patients.

HCPs who felt they had the necessary knowledge to connect their patients to resources had better experiences conducting screenings, with one social worker describing:

I felt good that I was able to understand what it was that the patient needed and their family and to be able to assist with providing some resources or information.

HCPs expressed overwhelming willingness to conduct screenings, but also shared many barriers to performing them effectively, with time being the most common. A maternal‐fetal medicine (MFM) physician described:

It often feels like it is work that is not reimbursed both financially or in time… providing healthy medical care to a perfect human being with all the resources fills an entire visit. And so you can't help but feel like you're being asked to do more than you've been given time to do.

3.2. Preferences on how to conduct screenings

When we asked HCPs their preferences around how screenings should be conducted; many noted the importance of in‐person conversations, with one social worker stating:

I feel like when you meet with someone in person you have the ability to see more–to communicate better, because they may say one thing to you verbally… however, their body language may say something different… So I do like the in‐person, because I can assess better and accurately.

The majority of HCPs recommended having patients fill out forms electronically prior to the appointment and then reviewing the answers in the office with the provider. However, a physician trainee indicated difficulty finding data:

I feel like there are questionnaires that patients fill out before their prenatal visits that I have no idea where the answers go… some of that data I see directly, but some of it I don't, because I just don't know where it lives…

Similar data concerns arose regarding documentation of in‐person screenings, with little consensus among the HCPs. While some electronic health record (EHR) systems have specific locations for SDoH information, many HCPs found that these weren't the most useful tools. Some HCPs tended to stick to commonly used processes already part of their workflow and more likely to be seen by other HCPs. The benefit of higher accessibility to other HCPs also added a concern around increased scrutiny of notes by patients. One social worker described:

Our patients also now have access to our notes, so I also have to be cognizant of that when I'm writing a progress note.

While most HCPs felt it was critical to screen for SDoH early in pregnancy, many stressed the importance of recurring screenings throughout the prenatal journey, in contrast to the general patient population who typically receive screenings annually. Participants highlighted the rapidly changing circumstances of pregnancy and the acute needs a pregnant patient may face. In addition, HCPs felt that screening at multiple points may allow patients to open‐up more after they feel more comfortable.

Participants indicated developing rapport can be a particular challenge in the prenatal setting, where patients often see different HCPs at each visit, limiting the ability to develop trust. An MFM physician recommended:

It's my firm belief that that trust is where that happens… so asking at intake whether you have access to food is not enough, like you need to then periodically readdress and have the ability to build the trust so that somebody might tell you what's actually happening

Most HCPs indicated that it was important to have a robust follow‐up process to make sure that recommendations weren't out of date and to get feedback on the quality of the services provided. One physician described her hopes for a follow‐up process as follows:

I think that is like actually a very important thing that I don't know if it happens, kind of the almost exit interview at the end of a pregnancy… so that we can modify our recommendations … if people tried to access resources that don't exist anymore, because things are constantly changing.

However, another physician was concerned that a follow‐up process could be problematic if it's done by a different individual than the one who conducted the screening, stating:

I think it would be a huge breach of trust to just have someone else say, hey, I read from so‐and‐so that you don't have enough food; I want to follow up on that.

3.3. Referral processes based on screening results

HCPs described taking extra care and time with patients most in need due to concerns that the patient would have difficulty following through themselves, as one social worker described:

Sometimes I may have to sit and actually set the service up or submit the referral for them because they won't actually do it, like if the depression is so disabling or impacting their ability to function.

Some SDoH categories are more common and have a vast landscape of resources to connect patients to. However, one nurse described how this can cause the resources to become overstrained quickly:

Food insecurity right now is a hot topic. So there's a lot more resources… As soon as they pop up, then they close very quickly, or they're overstrained because of the increased need.

The constantly changing landscape of referrals was a common problem. Some HCPs reported having a list of general resources to hand out to patients, but that given the changing nature of resources, it was hard to know how effective this list was. Some referral topics were reported to be easier to make connections to than others. Most HCPs had significant experience making referrals for transportation needs, and this was commonly identified as the need with the most available resources with one nurse practitioner saying:

Transportation for example, sometimes … are included in their state insurance policy and then a lot of people don't know that.

However, other HCPs noted that transportation systems may not be as accessible as they seem, due to the planning that needs to go into using them. Therefore, framing this as an easy fix could be offensive when it's not reflective of the patient's personal experience. A physician described:

If somebody has transportation barriers but they're already signed up for Modivcare and they just have trouble calling three days in advance, then you can focus more on that… even if you set up a time to be picked up, they may not actually be there at that time, and so particularly for a marginally housed population, that's not an easy thing, even.

Topics like anxiety and depression were perceived as harder to make referrals for, given the overall shortage of services. A nurse practitioner described:

Yeah, so as far as mental health resources, we're constantly giving patients like, here's a list of places that might be covered by your Medicaid insurance, and then the patients either don't continue trying, because it's not straightforward, and they're already dealing with stress and depression, hence the reason for needing the referral, so they get nowhere. Or, if they do get through, a lot of times there's a long wait list to see a provider.

Housing also posed an issue for HCPs, with one social worker describing:

Some of the resources, like housing, following up with the patient in three months, their housing situation is not gonna have changed, as far as a spot opening up on a waitlist.

Other HCPs described resources that are specific to the OB care population as more available. One medical assistant described providing diapers to a patient:

She asked us do we have any Pampers… she had a toddler and she had an infant. And we had it in‐house for her, so we give her that and we give her wipes to go along with the Pampers and the Pull‐Ups

HCPs also described referring patients to programs that provide car seats, milk supply resources, shakes to gain weight, and daycare programs. Daycare programs proved difficult for HCPs, given the shortage of these programs generally. Additionally, some programs only become available at a certain point in the pregnancy, reinforcing the importance of repeated screening and referrals throughout pregnancy.

3.4. Hopes for the future

Some HCPs described past experiences working in settings with a comprehensive screening process. Success came from centralized, integrated care and easily accessible referrals, with one physician describing:

When I worked at an FQHC…. We screened everybody. And we literally could walk down the hall to the social worker… everyone was literally in the same clinic, and the clinic was in the community.

Dedicated personnel and reimbursement also proved effective, with a midwife describing:

You had a dedicated RN who, every visit, would go over these things with the patient. And a lot of providers were very interested in this… program because… they would get better reimbursement for their prenatal care and delivery if they were enrolled in this. And it was an incentive to do it.

Other hopes for the future included holistic individualized treatment:

Right now it's such a turbulent time, in healthcare and everywhere else, that hopefully we're gonna have a breakthrough. And what will emerge will be holistic care that pays attention to all of these things… you wanna individualize it.

…hope for stronger patient‐HCP relationships:

The hope is continuity of care, having a baseline idea of the patient and their needs and developing a comfort level with them.

…and hope for more help and better outcomes:

I'm hopeful that if we're able to identify more we can help earlier and we can have better outcomes for our patients. That makes me excited to think about.

4. DISCUSSION

HCPs were interested and willing to conduct SDoH screenings, but there were many concerns regarding current processes. HCPs pointed to lack of time, evidence‐based best practices, resources, continuity of care, and reimbursement as hinderances to their ability to adequately and confidently implement screenings. However, respondents believed in the importance of screenings and had a desire to improve both processes and patient outcomes.

Lack of adequate training and resources were key contributors to HCPs feeling insecure in the screening process, which is in line with past literature. A 2019 review of SDoH training programs found that most had positive impacts on HCP's knowledge and attitude toward screenings [6]. A 2014 study included in the review found that participating in a training program increased trainees’ rates of resource referrals in the post‐curriculum intervention group [7].

Comprehensive SDoH training programs could increase confidence and effectiveness in screening, and health systems should consider implementing standardized training for all staff. However, many SDoH topics are not as actionable, and it may be unrealistic to expect HCPs to move the needle. Healthcare systems should train their HCPs on best practices for screening, referral, and documentation, including how best to support patients when there are no direct resources available.

Our results reflect a resource landscape that is difficult to navigate; maintaining an up‐to‐date index of available resources, including local, state, and federal, would help alleviate the pressure on HCPs. Such a list would need regular updating and to include clear steps for access. While this study builds on past literature that indicates the limitations in the capacity of many EHR systems to adequately track SDoH data and follow‐up [8], it also reinforces the need for comprehensive and coordinated referral systems which have proven effective when responsive to patient and HCP needs, strategically implemented, and regularly updated [9, 10].

The value of social workers carrying out referral connections was a common theme from HCPs to lessen some clinician burden. When resources allow, having a dedicated staff member, such as a social worker, to manage SDoH referrals may allow for more successful connections and follow‐up, while alleviating the burden on HCPs.

We consistently heard that HCPs felt that they were being asked to do more than time permitted. Recent trends incentivizing screenings and referrals have focused on targeted reimbursements such as tailored meals and transportation partnerships but have failed to address the implementation barrier of HCP time [11]. Institutions should adjust the structure of patient visits to incentivize and specifically allocate time for SDoH screenings. If institutions compensated or rewarded HCPs for screenings and referrals, it could justify the additional time required. While there is some prior work evaluating systemwide implementation of SDoH screening, such as in emergency departments [12], future work should determine best practices for implementation at this level. See Table 3 for a comprehensive list of health system recommendations.

TABLE 3.

Screening implementation recommendations.

Screening implementation recommendation	Detailed description
1. Need for a resource database	Clinics should develop and maintain a list of up‐to‐date resources to correspond with the different categories of SDoH screenings.
2. Need for standardized and comprehensive trainings	Clinics should develop trainings for their staff on screening best practices, resource landscapes, and strategies when there are no resources available.
3. Need for a dedicated staff member with knowledge of resource referrals	Clinics should have a designated referral point person who can support patients in accessing resources that relate to the topics they screened positive for. It is critical that the point person be supported in keeping up to date on changes in public benefits availability.
4. Need for incentives and reimbursement	Clinics should ensure that all reimbursements from SDoH screenings are invested back into implementation processes. When possible, clinics should provide incentives for staff members who successfully support patients who screen positive for SDoH needs.

Abbreviation: SDoH, social drivers of health.

While many of the current payment structures incentivize health systems, these data suggest that testing the effectiveness of incentives at the HCP level may be important to impacting SDoH screening success. Future research should engage payors and public entities to test models of reimbursement that include incentives or higher reimbursement rates for participating in evidence‐based screening and referral programs. Additionally, Community Health Workers (CHWs) have been employed by many health systems to help patients navigate SDoH, and more robust evaluation and coordination of these services is necessary [13]. This study was conducted at Penn Medicine, an urban university‐based health system, so findings may be limited in generalizability to other contexts. Perspectives may be skewed toward those passionate about improving this process—however, this limitation also likely leads to information‐rich interviews. Strengths included the wide variety of roles and length of tenure represented, as well as varying level of experience conducting screenings. However, this strength of diversity also limited the ability of the interviews to capture diverse experiences within individual roles. The study employed rigorous qualitative methods from conception through analysis.

5. CONCLUSION

Most HCPs felt a personal responsibility to talk to their patients about SDoH, believing these conversations allowed them to provide better care and build patient–clinician relationships. HCPs consistently articulated a desire to help patients improve health outcomes and their lives overall, while also reflecting on many factors limiting their ability to do so. This study illuminates how health systems can better support HCPs on the front lines of care delivery.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

Ethics approval for this study was obtained by the Institutional Review Board at the University of Pennsylvania, Review Board IRB #8. The IRB protocol number for the study is 852704. All study participants provided informed consent at the start of the study.