Integrating social context into comprehensive shared care plans: A scoping review

Highlights

• Shared care plans that include social determinants of health may improve outcomes.

• Policy-level initiatives to add social context into the care plan are emerging.

• Current evidence for best practices is primarily limited to consensus building.

• Interoperability, standardization, patient centeredness, and integration must occur.

• Fundamental research is necessary to establish a firm scientific foundation.

Abstract

Background

Failure to address social determinants of health (SDH) may contribute to the problem of readmissions in high-risk individuals. Comprehensive shared care plans (CSCP) may improve care continuity and health outcomes by communicating SDH risk factors across settings.

Purpose

The purpose of this study to evaluate the state of knowledge for integrating SDH into a CSCP. Our scoping review of the literature considered 13,886 articles, of which seven met inclusion criteria.

Results

Identified themes were: integrate health and social sectors; interoperability; standardizing ontologies and interventions; process implementation; professional tribalism; and patient centeredness.

Discussion

There is an emerging interest in bridging the gap between health and social service sectors. Standardized ontologies and theoretical definitions need to be developed to facilitate communication, indexing, and data retrieval.

Conclusions

We identified a gap in the literature that indicates that foundational work will be required to guide the development of a CSCP that includes SDH that can be shared across settings. The lack of studies published in the United States suggests that this is a critical area for future research and funding.