'Screen and refer' systems are hurting patients

By Sanjay BasuMay 22, 2023

I once saw a patient who came to the emergency room with injuries that were clearly related to domestic violence. Instead of offering a compassionate ear and a blanket to cover her exposed body after an assault, her intake nurse rushed through a checklist intended to screen her for social needs. While facing the computer screen, the nurse asked the patient a series of sensitive questions, including one about whether she had experienced domestic violence. The patient, feeling put off by the nurse's impersonal manner, denied having ever experienced any abuse.

In recent years, primary care providers like me have started to realize that we need to ask patients about all manner of topics, including domestic violence and whether they have access to a refrigerator if we prescribe a medicine that needs to stay cold. But these efforts have manifested themselves in the form of a rapid "screen-and-refer" approach, which involves asking patients to quickly complete checklists about their social needs and then automatically refer them to social service organizations.

The "screen-and-refer" approach has become increasingly popular at hospitals and clinics across the U.S. As I have learned, however, implementation is often flawed and overwhelms the very organizations meant to provide support. Ultimately, this well-intended but poorly executed system is not only ineffective but also dehumanizing — and even potentially harmful to patients.

When someone answers "yes" to screening questions, they are automatically referred to local community-based organizations like food banks, housing agencies, domestic violence services, or non-emergency medical transportation providers. But most of the referrals go unutilized due to a lack of program capacity and funding and low patient interest in the social services offered. When people do take advantage of the referral, the result is often that community-based organizations face overloaded waiting lists and appointments. Some of these patients are in desperate need, while others might have answered "yes" to a screening question but are unsure why they received an outreach they didn't ask for. Perhaps even more alarmingly, "auto-referrals" for social risk factors can also result in increased depression when patients are frequently screened but ultimately don't receive the help they need.

Perspective and commentary from experts around the world

Health care organizations often praise themselves in press releases for addressing social needs through increased patient screenings and referrals, while local organizations ranging from food pantries to housing agencies find themselves swamped and underfunded. In the process, those of us in health care delivery roles are missing the opportunity to connect with our patients, hear their stories, and truly understand their needs. By reducing our patient interactions to pressured button-clicking, we are denying people the dignity and respect they deserve.

Evidence suggests that a "narrative medicine" approach — in which we take the time to listen to our patients and understand their stories — is a more humane and effective alternative. Narrative medicine is premised on the idea that each patient should be treated as a person with an individual story to be understood, rather than a collection of symptoms to be screened and assessed. In a randomized clinical trial, the narrative approach adopted by community health workers has been shown to prevent avoidable illness events and generate a return of $2.47 for every dollar invested through personalized action plans and hands-on support.

By contrast, peer-reviewed research on the screen-and-refer approach often finds it ineffective and difficult to sustain in primary care practices — despite its aim to be more streamlined and efficient — due to poor implementation of software services, limited resources to develop and maintain lists of community resources, challenges matching referrals to patient needs, and inability to measure the efficacy of referrals.

Resistance to narrative approaches centers on valid concerns about time management. Too many providers are already struggling with unsustainable workloads and burnout. One potential solution to this dilemma is greater adoption of community-based care models, including multidisciplinary teams incorporating community health workers. As trusted frontline resources who often come from the communities they serve, community health workers act as a bridge between patients, providers, and social services organizations. They accompany patients to medical appointments and serve as "translators" between time-strapped providers and patients who are weary of the health care system. This work can include helping patients to better articulate their social needs and working with providers to appropriately refer them to social services organizations when needed. Numerous studies have shown that community health workers can help providers better address social risk factors and generate positive return on investment for payers.

I recently experienced the benefits of this approach with a patient who had been to the emergency room several times for chest pain and hypertension. There was an obvious social class divide between myself and my patient in the exam room, as the patient responded to my questions with one-word answers and passive agreement. But once he met a community health worker who had also been incarcerated in San Quentin prison like my patient, the patient immediately felt more comfortable talking about his blood pressure — and eventually admitted to his community health worker that he was functionally illiterate and nervous about being unable to read his medication bottles. The community health worker labeled a "sun" and "moon" pillbox for him to take daytime and nighttime medications with confidence, and the patient hasn't had chest pain or uncontrolled blood pressure since.

Returning to our roots in medicine means prioritizing meaningful social connections and empathic understanding. It means adopting a more nuanced and compassionate approach than assuming social needs can be addressed with a rapid click of the mouse, just like a lab order or prescription. As health care providers, we have a responsibility not only to treat our patients’ physical ailments but also to address social needs that impact their lives. We cannot do so if we continue to invest in a system that is more about patting ourselves on the back for checking a box than solving our patients’ problems.

Sanjay Basu, MD, Ph.D., is a primary care provider, epidemiologist, and head of clinical at Waymark, a public benefit company dedicated to improving access and quality of care for people receiving Medicaid benefits. He provides primary care, substance use, HIV, and hepatitis C treatment to patients at San Francisco's HealthRight360 Integrated Care Center for marginally housed adults.

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