Health-related social needs discussions in primary care encounters in safety-net clinics: A qualitative analysis

Importance: 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.

Objective: 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.

Main outcomes and measures: Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics.

Results: 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%).

Conclusions: 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.