Look for Undocumented Social Determinants of Health in Patient Charts
By Melinda Young
When case managers read charts that are missing some elements of social determinants of health, they might lack information important for a smooth transition.
- One common piece of missing data is whether a patient lives alone or with someone else.
- Missing data about who a patient lived with was associated with higher odds of revisiting the emergency department.
- Other data often missing include activities of daily living, employment status, and history of abuse.
One conundrum for hospital case managers involves identifying patients’ social determinants of health needs when the hospital record does not list all these data.
“Typically, when people are using data, they look at the data they see,” says Sue Feldman, PhD, RN, professor and director of graduate programs in health informatics at the University of Alabama at Birmingham.
But the visible data could be missing critical factors related to why patients are returning to emergency departments (EDs) or are not taking their medications. For example, a recent study revealed comorbidity data were more likely to be omitted in patients with few comorbidities. One major social determinant of health omitted in data is whether a patient lives alone or with other people.1
“A data element that was missing and of statistical significance was this element called ‘lived with…,’” Feldman explains. “If that information is not collected, then you don’t know if they live by themselves or with others.”
When it is time to safely transition patients to the community, this information can be crucial to understanding the patient’s risks for returning to the ED or being rehospitalized.
Study results showed 12 social determinants were missing from a de-identified data set of 123,697 people who visited the University of Alabama at Birmingham Medical Center ED at least once in 2017. Among the 12 social determinants, the missing data pertaining to whether the patient lived alone was associated with higher odds of ED revisits.1
“The other thing that was surprising was when we looked at comorbidities, relative to data missing, we found that those with fewer comorbidities had more missing data. That was curious to us,” she adds. “I can’t help but think there was some unconscious bias going on there.”
It is possible nurses, case managers, ED intake staff, and others did not ask about comorbidities from every patient, especially if the patient appeared to be healthy.
“What could be happening is ‘Because I think you are healthy, I’m not going to go through and ask all of these questions because they might not apply,’” Feldman says. “But we know from the opioid epidemic, for example, that this could not be further from the truth: Opioid abusers might not fit the typical drug user demographic, so there could be a whole lot of information we’re missing.”
Among the oft-missing social determinants of health data include:
- Activities of daily living;
- Living situation;
- History of abuse;
- Employment status;
- Problems at home.
“We found the things that were the most predictive of revisits to the ED were things like the pain score, activities of daily living, and living situation,” Feldman says. “Living situation came up twice in the study. It’s interesting how many times that was not collected.”
The paper was written to encourage thinking about knowledge gaps in transitions of care from the hospital to home. “If we know more before we transition our patients out of the hospital, then we potentially could provide better and more targeted services for that person’s needs,” Feldman explains. “We could help patients avoid future trips to the emergency department, or readmissions.”
A chief cause of readmission is when patients delay their health needs until the problem becomes a crisis or catastrophic, she says. Many health conditions should have been managed in the ambulatory environment through patients’ health clinics or primary care providers. But case managers and others working with at-risk patients are not always armed with the best and most up-to-date information about the patient’s health issues and social determinants of health.
“If patients received the right services, right attention, and everything focused on their needs, then I wonder if we could decrease the amount of catastrophic care,” Feldman says.
This is tied to the process of transitioning patients from the hospital to their home. Often, case managers have too many patients to deal with and challenging discharge deadlines to meet. “There are all of these confounding factors,” Feldman says. “But I am proposing that this is not just to focus on the right social determinants for that patient. It’s not about requiring more time from case managers, but requiring the right focus of time.”
For example, if a case manager is sending a patient home and does not know whether the patient lives alone, then this missing information could affect follow-up care. The patient who lives alone might need home care services and someone to ensure the person has enough food and is eating well, she explains. The key is for case managers, nurses, social workers, and hospital ED intake staff to collect all the social determinants of health listed in their electric health record every time they screen a patient.
“Don’t assume that this information is not important for this patient,” Feldman says. “I think the opioid epidemic has opened our eyes that issues like substance use cross all geographic and social barriers.”
Case managers could anticipate missing social determinants of health information in patients’ medical records and ask questions when they see information, such as their living status, is not listed.
“Sometimes, it’s hard to get this information from patients; some people might be incoherent or unable to answer,” Feldman says. “You’ll need to get ahold of their family and friends or neighbors.”
It also is important for case managers to think about expanded social determinants. For instance, access to the internet could be considered a social determinant of health in 2020, while it was not an issue in 2000.
“Now, internet access can impact someone’s health outcomes because of their ability or inability to seek health information,” Feldman says. “Then, there’s the health literacy level to think about.”
This research into the missing social determinants of health is the tip of the iceberg. “I am hopeful it will get more people to look at what’s missing and the value of what’s missing,” Feldman says.
- Feldman SS, Davlyatov G, Hall AG. Toward understanding the value of missing social determinants of health data in care transition planning. Appl Clin Inform 2020;11:556-563.
One conundrum for hospital case managers involves identifying patients’ social determinants of health needs when the hospital record does not list all these data. The visible data could be missing critical factors related to why patients are returning to emergency departments or are not taking their medications.
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