Improving Understanding of Screening Questions for Social Risk and Social Need Among Emergency Department Patients

With recent healthcare policy changes, including the creation of accountable care organizations, screening for social risks such as food and housing insecurity has become increasingly common in the healthcare system. However, the wide variety of different tools used for screening makes it challenging to compare across systems. In addition, the majority of tools used to measure social risks have only been tested in primary care settings and may not be optimal for emergency department (ED) use. Therefore, the goal of this study was to create a brief social screening tool for use in EDs.

We developed an initial tool using publicly available questions corresponding to the five core categories of the Centers for Medicare & Medicaid Services' Accountable Health Communities Screening Tool. Iterative cycles of cognitive interviews with purposively sampled participants were performed using a hybrid model of think-aloud and verbal probing to understand/experience answering questions and potential comprehension challenges. After thematic saturation was reached in one cycle, the tool was changed per participant input; cycles were completed until thematic saturation was reached overall.

A total of 16 participants (six patient guardians and 10 patients) completed cognitive interviews throughout three cycles. Participant feedback included suggestions for further clarification and simplification of survey questions for improved comprehension. The survey was thus reduced and simplified from 16 questions concerning five domains to 10 questions concerning four domains.

We used an iterative cognitive interviewing process to develop a social screening tool for use in EDs. This process demonstrates the importance of patient input to refine questionnaires, and provides a brief screening tool for ED use.