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. 2022 Dec;57(12):3035-3043.
doi: 10.1002/ppul.26131. Epub 2022 Sep 14.

Social determinants of health screening and intervention: A cystic fibrosis quality improvement process

Deirdre Jennings  1 , Rhonda List  2 , Heather Bruschwein  3 , Martina Compton  2 , Lindsay Somerville  2 , Lauren Williamson  2 , Rachel Murray  2 , Brielle Evangelista  2 , Dana Albon  2
Affiliations

Social determinants of health screening and intervention: A cystic fibrosis quality improvement process

Deirdre Jennings et al. Pediatr Pulmonol. 2022 Dec.

Abstract

Introduction: Lower socioeconomic status is associated with significantly poorer outcomes in weight, lung function, and pulmonary exacerbation rates in people with cystic fibrosis (PwCF).

Global aim: We aim to reduce health disparities and inequities faced by PwCF by screening for and addressing unmet social needs.

Specific aims: We aimed to increase routine social determinants of health (SDoH) screening of eligible PwCF from 0% to 95% and follow-up within 2 weeks for those PwCF who screened positive and requested assistance from 0% to 95% by December 31, 2021.

Methods: The Model for Improvement methodology was used. A process map and a simplified failure mode effects analysis chart were created for the screening and SDoH follow-up process. For those who screened positive for SDoH and requested assistance, follow-up contact was made to offer intervention.

Intervention: Adult PwCF who had at least one UVA Clinic encounter in 2021 were screened for SDoH. The SDoH screening tool included eight domains: housing, food, transportation, utilities, health-care access, medication access, income/employment, and education. Follow-up was completed with all PwCF who screened positive for SDoH.

Results: A total of 132 of 142 (93.0%) PwCF eligible for screening completed the SDoH screening. Of the PwCF who completed screening, 56 (42.4%) screened positive for SDoH. A follow-up rate of 100% was achieved in June 2021 and maintained through December 2021.

Conclusion: Implementing screening for SDOH and follow-up to mitigate social difficulties in adult PwCF at UVA was successful and could be reproduced at other CF care centers.

Keywords: Model for Improvement; Plan-Do-Study-Act; cystic fibrosis; social determinants of health; social risk factors.

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Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Process map for routine SDoH screening and intervention process. MyChart, Health Insurance Portability and Accountability Act (HIPAA) secure messaging system through patient electronic medical record; SDoH, social determinants of health; SW, social worker.
Figure 2
Figure 2
SDoH screening and intervention simplified failure mode effects analysis (sFMEA). CF, cystic fibrosis; MyChart, Health Insurance Portability and Accountability Act (HIPAA) secure messaging system through patient electronic medical record; SDoH, social determinants of health.
Figure 3
Figure 3
Annotated chart tracking the progress of percentage of PwCF screened during screening process testing. PwCF, people with cystic fibrosis.
Figure 4
Figure 4
Annotated chart tracking the progress of testing percentage of patients who scored positive for SDoH and requested assistance who received follow‐up within 2 weeks. SDoH, social determinants of health.
See this image and copyright information in PMC

References

    1. Cystic Fibrosis Foundation. Patient Registry 2020 Annual Data Report. 2021.
    1. Oates GR, Schechter MS. Socioeconomic status and health outcomes: cystic fibrosis as a model. Expert Rev Respir Med. 2016;10(9):967‐977. 10.1080/17476348.2016.1196140 - DOI - PubMed
    1. Schechter MS, Shelton BJ, Margolis PA, Fitzsimmons SC. The association of socioeconomic status with outcomes in cystic fibrosis patients in the United States. Am J Respir Crit Care Med. 2001;163(6):1331‐1337. 10.1164/ajrccm.163.6.991210010.1016/j.jpeds.2009.04.059 - DOI - PubMed
    1. Center for Disease Control and Prevention. About Social Determinants of Health (SDOH). 2022.
    1. Tumin D, Crowley EM, Li SS, Wooten W, Ren CL, Hayes D. Patterns of health insurance coverage and lung disease progression in adolescents and young adults with cystic fibrosis. Ann Am Thorac Soc. 2021;18(2):290‐299. 10.1513/AnnalsATS.201911-839OC - DOI - PubMed

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