Implementing Social Determinants of Health Screening in US Emergency Departments

Importance: Screening for adverse social determinants of health (SDOH) in the emergency department (ED) may help reduce health disparities in underserved populations. Objective: To understand barriers and facilitators to screening, documenting, and addressing adverse SDOH in a diverse sample of US EDs. Design, Setting, and Participants: This qualitative study used in-depth interviews with leaders of a purposive sample of EDs across urban, rural, academic, and community settings who self-reported screening for adverse SDOH on a prior National Emergency Department Inventory (NEDI) USA survey. EDs that completed the 2022 NEDI-USA survey and reported adverse SDOH screening were eligible for recruitment. Eligible participants were interviewed in April to September 2023. Inductive thematic analysis was conducted from September 2023 to January 2024 to identify themes and concepts. Main Outcomes and Measures: Themes and concepts related to ED practices for adverse SDOH screening and referral. Results: From 77 eligible EDs, 27 leaders agreed to be interviewed, (18 66.7% female; mean range age, 44 30 to 63 years; mean range time in current role, 3.25 <1 to 12 years). Participants worked in a variety of leadership roles (eg, chair or medical, nursing, or operations director). Findings centered around heterogeneity in ED adverse SDOH screening and documentation practices; skepticism of utility of ED adverse SDOH screening and referral; drivers of ED adverse SDOH screening, such as regulatory mandates for the expansion of adverse SDOH screening; resource, staffing, and time constraints in adverse SDOH screening and linkage to services processes; and recommendations and suggestions for improving the implementation of ED adverse SDOH screening, such as tailoring validated tools to the ED context and ED stakeholder engagement in designing the screening process. Other suggestions included having additional dedicated screening staff, particularly social workers, and strengthening relationships with existing non-ED SDOH initiatives and community resources dedicated to addressing adverse SDOH. Conclusions and Relevance: This qualitative study of US EDs describes an overview of practices and challenges surrounding adverse SDOH screening and identified novel solutions and areas where more research is needed for the successful implementation of adverse SDOH screening in the ED setting. At the policy level, regulatory mandates instituting adverse SDOH screening should include provisions for funding to support patient needs identified by screening. Additional research on development and implementation of ED adverse SDOH screening programs is needed.