Who Addresses Social Determinants of Health in Primary Care?

Problem

Social determinants of health (SDH) influence an individual’s overall health yet are often considered outside the scope of traditional medicine. Greater primary care capacity to address these social determinants of health is a needed component in the ongoing transition to more comprehensive, patient-centered care models. Since it is unlikely that primary care providers (PCPs) alone can fully address SDH, we sought to identify which roles in primary care practices currently address SDH and whether characteristics such as team culture, full or part-time schedule, and years worked with a clinic influence this association.

Approach

We administered a survey to 891 clinicians and staff at 13 county-based and 6 university primary care clinics between November and December 2015 (response rate 73%). Respondents identified on a scale of 1-10 (strongly disagree to strongly agree) whether, “I routinely address the social needs of my patients through connecting them with resources, dedicated staff, or tools.” The outcome was dichotomized into “yes” (9 or 10) or “no” (1-8) due to its skewed distribution. Roles were categorized as non-resident PCPs, resident PCPs, medical assistants, registered nurses, front office, behavioral health specialists and social workers, and other. Analysis included bivariate tests for significance between addressing SDH and clinic roles. A multivariate logistic regression model with clustering by clinic also included a team culture, full or part-time schedule and years worked with the clinic.

Findings

Respondents overall highly agreed that addressing SDH is part of their routine work (mean response = 8.0 out of 10, SD= 2.02). In bivariate analysis, levels of addressing SDH differed significantly by role (p-value = 0.000 for overall X2). In particular, 81.2% of behavioral health specialists and social workers reported “yes” (9 or 10) for addressing SDH, a statistically significant higher level than all other roles (medical assistants 48.0%, registered nurses 50.5%, front office 41.5%, non-resident PCPs 52.7%, resident PCPs 35.0%, and other 59.4%). This significant association remained when controlling all other factors using non-resident PCPs as the reference group (odds ratio 1.7, p-value=0.001). There were no statistically significant differences among other roles compared to non-resident PCPs when controlling for other factors. Team culture, as assessed by the team culture scale, was positively and significantly associated with addressing social determinants health in multivariate modeling (odds ratio 1.3, p-value =0.000). However, when team culture by role was examined for a potential interaction effect, no significant differences were found (one-way anova, p-value = 0.18).

Consequences

Our findings suggest that addressing SDH is fairly common among PCP and staff roles, though behavioral health specialists and social workers address SDH most frequently. Increased efforts to integrate behavioral health specialists and social workers into primary care could be an important strategy to specifically addressing SDH in these settings.