Increasing the assessment rates of the social determinants of health (SDoH) in patients with newly diagnosed breast cancer at a safety-net health system.
Authors: Hodges Mary P , Ruiz Helen , Dreadin-Pulliam Julie , Dickerson Umber , Anwar Iman , Spannagel Tennesse , Mohamed Ashraf , Semlow Andrea R. , Cobb Robyn , Sadeghi Navid 
Published: October 2023

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Background: SDoH are non-medical factors that can influence health outcomes. The negative impact of SDoH on vulnerable populations such as racial and ethnic minorities contributes to health disparities; therefore, consistent, accurate, and comprehensive assessment of SDoH is a first step towards promoting health equity and eliminating disparities. This is particularly important in safety-net systems where the patients’ burden of SDoH is disproportionately high. In this quality improvement project, we aimed to increase the SDoH assessment rate from the initial visit for newly diagnosed breast cancer patients. Methods: Parkland Health (PH) is one of the largest safety-net systems in the US and is affiliated with the UT Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). PH provides a wide range of support services such as transportation, childcare, medication assistance, nutrition education, etc., to patients, however, these services are likely underutilized due to a lack of consistent and accurate assessment of patient needs. A multidisciplinary team, supported by the ASCO Quality Training Program and sponsored by the Susan G. Komen Foundation, mapped the relevant clinic processes and performed a root cause analysis. Interventions included developing the relevant policies and procedures, electronic health record training, and interview training (first PDSA cycle). SDoH assessment was initially included in the Oncology Nurse Navigator (ONN) workflow but later was expanded to include clinic nurses (second PDSA cycle). The goal of the project was to increase SDoH assessment within 2 weeks from the initial clinic visit to 50%. Results: In the year before the intervention, the SDoH assessment rate for newly diagnosed breast cancer patients was at 2.7%. Incorporating SDoH assessment into the ONN’s workflow resulted in an initial increase in the completion rate to 31%, however, we observed a subsequent drop in the assessment rate to a monthly average of 15%. Reasons included the ONN’s patient panel size (350 new breast cancer patients annually), competing navigation priorities, and concurrent clinics. In the second PDSA cycle, all RNs were trained on completing SDoH assessments. In the 7 weeks following the second PDSA cycle, the assessment rate rose to an average of 76% per week. Conclusions: We increased the SDoH assessment rate from a baseline of 2.7% to 76% by improving workflows and leveraging current resources. Based on the lessons learned, we plan to add another ONN position to make the patient panel size more manageable. In addition, we plan to use MyChart messaging and tablets to self-administer the SDoH questionnaire to patients during the visit. These strategies allow to expand of the SDoH assessment for established patients, accounting for evolving patient needs throughout their cancer journey.