Commentary on “A qualitative assessment of barriers and facilitators associated with addressing social determinants of health among members of a health collaborative in the rural Midwest”

Implementing novel approaches to responding to patients’ unmet social needs (e.g., food insecurity, housing instability, social isolation), or downstream consequence of social determinants of health, in primary care is an important mechanism for advancing health equity and value-based care. However, interventions and/or programs that respond to unmet social needs are especially influenced by contextual factors across multiple levels including the patient, provider, organization, community, and system/policy levels. For example, responding to unmet social needs requires multi-sector coordination and often depends on policy-level determinants that promote or inhibit the availability of health care and social assistance. Understanding the impact of these implementation factors, within each level and across multiple levels, is critical in developing impactful and sustainable approaches to improving health outcomes.

A recent article by Dauner et al, explores the complex interplay across multiple levels to understand barriers and facilitators, and the capacity to addressing social needs within a collaborative of independent provider organizations in rural Northeastern Minnesota and Northwestern Wisconsin. Dauner et al’s evaluation of health care delivery across different organizations in a collaborative and related population health activities sheds light on the key contextual drivers of implementation in a rural setting. Notably, the findings highlight the unique economic and social structures, population health risks, and health system fragmentation that exist within rural communities. Findings indicated nuanced organizational-, community-, and external/state-level drivers due to the author’s leveraging their expertise in rural health research; a realist framework to obtain key stakeholders’ motivations and reasonings; prior data on Chaudoir et al to guide questioning and probing selection; and Greenhalgh et al’s Model for Diffusion of Innovations in Service Organizations. One impactful finding is that numerous barriers (e.g., heterogenous payment and reimbursement mechanisms, resource availability, workforce capacity) exist to addressing social needs despite organizational partnerships with social service agencies and development of shared guidelines and innovative strategies for integrating social care.

In summary, Dauner et al is a scientifically rigorous step in identifying and understanding the organizational-, community-, and external/state-level determinants that impact social needs screening in rural settings. A focus on identifying discrete policies and structural reforms that can complement strategies at the organizational or individual level is critical. A key area of research in implementation science is the study of how, when, where, why, and in what ways contextual factors impact uptake and adoption of an evidence-based intervention. Further research by implementation scientists can help inform the development of contextually relevant, multi-level approaches, to promote uptake and adoption of social needs screening and response in health care settings.

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