De Leon Elaine, Panganamamula Sneha, Schoenthaler Antoinette
Department of Medicine, NYU Langone Health, New York, New York.
Institute for Excellence in Health Equity, NYU Langone Health, New York, New York.
JAMA Netw Open. 2025 Mar 3;8(3):e251997. doi: 10.1001/jamanetworkopen.2025.1997.
Health-related social needs (HRSN) influence health outcomes and health care utilization. Clinicians face challenges addressing HRSN due to limited skills, expertise, and time. Further insight is needed on how patients and clinicians navigate HRSN in clinical encounters.
This study examines outpatient primary care encounters predating widespread HRSN screening to identify how discussions on HRSN are initiated and addressed.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative analysis was conducted on transcripts of 97 audiotaped English-speaking patient encounters from 3 clinics in New York City within a municipal health care system from January 2011 through April 2015. Patients were eligible if they were older than 18 years, self-identified as Black or White, had a diagnosis of hypertension, and had at least one prior encounter with the participating clinician. Codes were developed from social needs domains addressed by the Accountable Health Communities HRSN Screening Tool. Codes were added for further social needs identified, whether a patient or clinician initiated the HRSN discussion, and how a social need was addressed, if at all. Encounters were analyzed between June 2023 and February 2024.
Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics.
A total of 97 patients (55 [56.7%] women, 58 [59.8%] Black, mean [SD] age, 59.7 [10.6] years) had audiotaped encounters with 27 clinicians (18 [66.7%] women, 15 [55.6%] White, mean [SD] age, 36 [5.8] years). Physical activity (36% of encounters), financial strain (35%), mental health (34%), and substance use (28%) were the most discussed HRSN domains across the 97 encounters. Patients introduced financial strain most often (70% of the time), while clinicians led substance use (75%), physical activity (51%) and mental health (51%) discussions. Patients initiated conversations on employment (77%), food insecurity (62%), and housing instability (52%). Interventions included prescriptions, forms, counseling, and referrals. Domains frequently intervened on included health care navigation needs (85% of discussions), substance use (33%), and mental health (27%).
In this qualitative study of HRSN discussions in primary care encounters, clinicians were more likely to initiate discussions on substance use, physical activity, and mental health, behaviors routinely assessed in primary care, but different from topics introduced by patients. Findings underscore the need for standardized screening to improve identification of domains less frequently addressed by clinicians. Additional interventions are also needed, including clinician training for how to address HRSN in resource-constrained settings and integration of other health care team members, to enhance HRSN identification and intervention.
与健康相关的社会需求（HRSN）会影响健康结果和医疗保健利用情况。由于技能、专业知识和时间有限，临床医生在应对HRSN方面面临挑战。需要进一步深入了解患者和临床医生在临床诊疗过程中如何应对HRSN。
本研究调查了在广泛开展HRSN筛查之前的门诊初级保健诊疗过程，以确定关于HRSN的讨论是如何发起和处理的。
设计、背景和参与者：本定性分析基于2011年1月至2015年4月在纽约市一个市政医疗系统内3家诊所的97次英语口语患者诊疗录音文本。年龄超过18岁、自我认定为黑人或白人、被诊断患有高血压且此前至少与参与诊疗的临床医生有过一次接触的患者符合入选条件。编码依据可问责健康社区HRSN筛查工具所涉及的社会需求领域制定。针对识别出的其他社会需求、发起HRSN讨论的是患者还是临床医生以及社会需求是否得到处理（若得到处理）等情况添加了编码。2023年6月至2024年2月对诊疗记录进行了分析。
对安全网诊所临床诊疗过程中HRSN讨论的内容和性质进行描述。
共有97名患者（55名[56.7%]女性，58名[59.8%]黑人，平均[标准差]年龄59.7[10.6]岁）与27名临床医生（18名[66.7%]女性，15名[55.6%]白人，平均[标准差]年龄36[5.8]岁）进行了录音诊疗。在这97次诊疗中，身体活动（36%的诊疗）、经济压力（35%）、心理健康（34%）和物质使用（28%）是讨论最多的HRSN领域。患者最常提及经济压力（70%的情况），而临床医生主导了物质使用（75%）、身体活动（51%）和心理健康（51%）的讨论。患者发起了关于就业（77%）、粮食不安全（62%）和住房不稳定（52%）的对话。干预措施包括开处方、提供表格、咨询和转诊。经常进行干预的领域包括医疗保健导航需求（85%的讨论）
