Collaboration Is Key When Implementing SDOH Screening Programs


Properly training staff and gaining stakeholder buy-in are crucial steps to successfully designing and launching a program to screen and address health-related social needs.

Collaborating with all stakeholders is crucial when trying to implement a program to screen for and address social determinants of health (SDOH), said presenters in a session at the Pharmacy Quality Alliance 2024 Annual Meeting happening in Baltimore, Maryland, from May 14, 2024 through May 16, 2024.

Although SDOH have become a well-known concept among health care professionals, presenter Shanece Green, PharmD, RPh, MSPH, MBA, said health-related social needs (HRSNs) are another layer to consider, and are found within the every category of SDOH (eg, education, economic stability, social and community context, neighborhood, and health care access). In order to address all of these interconnected challenges, Green urged attendees to move beyond a linear way of thinking and into systems-based thinking, which can help to show how individual metrics of SDOH are interconnected.

“Health equity aims to prevent health disparities rooted in factors like race, gender, income, and geography, and these factors play a crucial role in shaping the overall health and lives of patients,” Green said.

The 3 broad steps to implementing a SDOH screening program and addressing these obstacles are evaluating patients and their unique challenges; collaborating with social workers, community health partners, and other stakeholders; and connecting patients with these resources. In a pilot program implemented at CPS Solutions, LLC, Green and her fellow panelists said they identified some best practices and recommendations for similar programs.

Before developing a program to screen and address HRSNs, presenter Casey Fitzpatrick, PharmD, BCPS, explained that pharmacy and health system leaders must consider their staff bandwidth, limits of available technology, the need for training, and potential concerns of both patients and staff. For instance, whereas patients might have concerns about why they are being asked about their housing situation, pharmacy staff may be concerned about potentially uncomfortable situations during these conversations. Training staff on specific challenges patients might discuss (domestic violence, housing instability, food accessibility, etc) and how to respond can be helpful, according to Fitzpatrick.

Secondly, Fitzpatrick said selecting a screening tool should be a carefully considered process. Some important considerations are whether the tool has validated questions, whether it is operationalizable in the daily workflow, and whether it has adequate options for the variable health literacy levels and different spoken languages of the target patient population. Tools can be interpersonal (eg, face-to-face or over the phone), as well as intrapersonal (eg, via a patient portal or a written form).

“What’s nice is there’s a lot of flexibility out there, and again, you have to consider your bandwidth and workflow,” Fitpatrick said.

During the patient encounter, ensure that staff members are trained to inform the patient about why this information is being collected and who it might be shared with. Having the patient sign a waiver allowing this information to be shared with a social worker or other stakeholders might be something to consider. Additionally, staff members should verify the patient’s contact information and discuss any individuals who may contact them to offer further assistance.

SDOH screening

During the patient encounter, ensure that staff members are trained to inform the patient about why this information is being collected and who it might be shared with. Image Credit: © StratfordProductions -

Importantly, Fitzpatrick acknowledged that there are no agreed-upon standards for SDOH documentation. Ideally, this would take place in a pharmacy patient management system and electronic health record (EHR), but this is not always possible. Fitzpatrick said his team found that using Z codes (Z55-Z65) was viable because they can be documented in the EHR and can be utilized for reimbursement purposes in a health system environment. Furthermore, several pharmacy system vendors have built clinical documentation modules to capture SDOH data.

In order to connect patients with appropriate resources, pharmacies should compile an SDOH resource document that can be easily accessed to either be given to the patient or for pharmacy staff to reference during their patient encounters. This document should include local, state, and national resources, as well as predetermined referral pathways such as health system social services, local health department social workers, and community organizations.

Examples of various interventions include food banks and Supplemental Nutrition Assistance Program application assistance for patients who are food insecure; community shelters and income-based housing for those who are housing insecure; transit vouchers or ride share programs for those without access to reliable transportation; and counseling services or domestic violence programs for those with concerns about interpersonal safety. Fitzpatrick added that copay assistance programs and discount cards are interventions for patients with economic stability concerns, highlighting ways that pharmacies are frequently involved in SDOH management, often without even realizing it.

Finally, presenter Kristin M. Darin, PharmD, BCPS, discussed their team’s specific pilot program and its findings. They work in an embedded clinic model, which is a benefit because the team already had experience matching needs to resources, access to pharmacy systems and health records, and data-driven models to improve outcomes.

In their program, the health system specialty pharmacy (HSSP) team screened for and identified HRSNs using a 10-question tool. The questionnaire addressed food insecurity, utility help needs, education, financial strain, transportation challenges, interpersonal safety, housing instability, and family and community support.

“I kind of looked at this project as an opportunity to really standardize these conversations and these processes that I was already doing,” Darin said. “It also gave me an opportunity to develop those outside relationships with actual social workers so that I could complete that step and make that referral.”

If a social need was identified based on the conversation with the patient, a follow-up question was asked regarding whether the patient wanted help with that need, via either an in-the-moment resource referral or future connections with a social worker or other stakeholder. The program was rolled out at 2 locations between September and December 2023.

In total, 44 patients were screened and 1 declined. About two-thirds were male, just over 50% were White, and patients had a median age of 53 years. Twenty-six patients had an HRSN identified, including food (52%), transportation (44%), utilities (37%), and housing (37%). Furthermore, about 20% identified at least 2 HRSNs and another 20% identified 3 or more HRSNs. Of those who had an identified HRSN, 96% received support, including 17 referrals to a social worker and 19 who received support or resources from a pharmacist. Future efforts are in place to assess long-term outcomes.

Darin acknowledged that this was a heavy lift for the pharmacist, and said the program needs to be assessed for scalability and sustainability. She also said collaboration with the health system and community partners is crucial to find ways to best document the identified social needs and incorporate these data with other initiatives in the health system.

Fitzpatrick added that funding opportunities present another significant hurdle to implementing similar SDOH programs. In health systems, Centers for Medicare and Medicaid Services reimbursement for inpatient and long-term care hospitals is required in 2024, and there are financial incentives for those with value-based care models. He also emphasized the potential cost avoidance associated with addressing HRSNs, including decreased hospital admissions and readmissions.

Unfortunately, funding in community pharmacies can be even more challenging, with no uniform reimbursement model. Potential options include charitable foundations, government agency grants, and private organizations. If provider status were to become a reality, Z code reimbursement could also be a future option.

Even with these challenges to address, all 3 presenters emphasized the value of these programs for patients. Darin highlighted one patient who came to the clinic with newly-diagnosed HIV, and who is now adherent to his treatment medicine, receiving monthly food boxes, and at the top of the list for local housing assistance.

“I really want you to think of this as an expansion of our current pharmacy practice models,” Darin said. “We’re really building upon and creating a more holistic approach.”


Darin KM, Green S, Fitzpatrick C. A Health System Specialty Pharmacy Team’s Role in Addressing Social Determinants of Health. Presented at: Pharmacy Quality Alliance 2024 Annual Meeting. Baltimore, MD; May 15, 2024.

Related Videos
Pride flags during pride event -- Image credit: ink drop |
Female Pharmacist Holding Tablet PC - Image credit: Tyler Olson |
pain management palliative care/Image Credits: © Aleksej -
African American male pharmacist using digital tablet during inventory in pharmacy - Image credit: sofiko14 |
palliative and hospice care/ Image Credits: © David Pereiras -
Young woman using smart phone,Social media concept. - Image credit: Urupong |
multiple myeloma clinical trial daratumumab/ Image Credits: © Dragana Gordic -
multiple myeloma clinical trial/Image Credits: © Studio Romantic -
3d rendered illustration of lung cancer 3D illustration - Image credit:  appledesign |
© 2024 MJH Life Sciences

All rights reserved.