A broader view of social determinants of health
Because of the outsized role of SDOHs in healthcare, strategies and tactics for addressing social determinants are getting more attention and moving further upstream compared to downstream efforts like medical intervention and clinical care. This matters: For some patients, social and mental health intervention is the only way to successfully manage their medical conditions over the long term.
Screening patients about social and economic factors is becoming the norm in more and more healthcare settings, which in turn informs care and opens the door for referrals to help individuals get their basic needs, like food, shelter, and clothing, met. According to a recent (April 2019) Medical Group Management Association poll, 52% of healthcare leaders indicated they screen patients for social determinants, mainly regarding food security (40%) and transportation (37%).
Bon Ku, MD, director of the Health Design Lab at Thomas Jefferson University, says it's crucial for physicians to be as concerned about social determinants as they are about medical interventions for patients.
“It's impossible to divorce physical health and mental health when someone is suffering from both, which is often the case," said Ku. “Mental health goes under-diagnosed because it's stigmatized. I think we need to treat mental health issues with the same sort of mindset we treat chronic conditions like diabetes and hypertension."
To that end, social services and mental healthcare programs are beginning to show promise with specific populations as potential gateways to lasting engagement.
Solutions and success stories
Since 2017, Hayward Wellness, an ambulatory health clinic in the Alameda, California, health system, has successfully screened 95% of patients for SDOH factors, identifying 17% to 19% as food insecure. But they didn't stop there. With seed funding from Kaiser Permanente's Community Benefit program, Hayward created a network of both in-house and community resources grouped into three “pharmacies" that align to drivers of health: food, social needs, and behavioral health.
In addition to writing 1,400 food pharmacy and 550 social needs pharmacy “prescriptions," Hayward saw a 2% decrease in HbA1c levels in more than 100 patients. They're hoping it's just the beginning.
“Providers often feel overwhelmed by the gap between screening for important issues and the actual delivery system for intervention.”
Steven Chen, M.D., medical director at Hayward, said providers often feel overwhelmed by the wide gap between screening for important issues such as social determinants and the actual delivery system for intervention. Providers don't feel they can make a difference, which can contribute to burnout.
“It's messy and complicated to address social determinants and it requires patience," said David Barash, M.D., an emergency physician in Massachusetts, and executive director at the GE Foundation. “There are proven models that meet the short-term medical needs of patients as well as connecting them to housing or employment services to change health outcomes over the long-term."
This lengthy waiting period is partly why quantifying the impact of some SDOH programs has been slower to emerge — and in some cases, why such programs have been slow to receive needed funding.
At Cincinnati Children's Hospital, a legal advocacy program called Child Health-Law Partnership (Child HeLP) was launched in 2008 to provide legal resources to support individuals and families with “health-harming legal needs." More than 6,000 patients have been referred to the partnership since its founding.
After integrating their population-based assessments with the ongoing Cincinnati Children's Asthma Improvement Collaborative, an organization aimed at reducing hospitalizations for children on Medicaid, hospitalization rates dropped by more than 40% over an eight year period.
Joel Teitelbaum, co-principal investigator at the National Center for Medical-Legal Partnership, says the Child HeLP program is one of more than 350 such partnerships that have formed, with more under development.
“The more we recognize and want to address the role of social determinants in health, the more partnerships we are going to need," Teitelbaum says. “I think it's totally unfair of us to under-spend on social services and basically foist onto the medical care system the responsibility to somehow fix it."
Aiming for better outcomes, not just services provided
As state Medicaid programs emphasize paying for health outcomes (versus volume of healthcare services delivered), evidence supports addressing social determinants with qualified Medicaid enrollees first, given its cost-effectiveness with higher-need populations.
According to the Robert Wood Johnson Foundation, providing supportive housing to the seriously mentally ill who would otherwise be homeless reduces medical expenditures on ED visits and inpatient care. Additionally, connecting lower-income older adults with chronic conditions to the Supplemental Nutrition Assistance Program (SNAP) or home meal delivery can reduce overall healthcare costs and utilization.
In order to significantly impact population health, hospital leaders and physician staff will likely need to continue forming partnerships to support more community-related outreach given that many of these programs are underfunded.
Barash says that perhaps the next step is convincing payers to partner by contributing funding of their own. “As we measure social determinants, it's one thing to start seeing changes in health outcomes, but it's another thing to start showing payers that investment in social determinants will ultimately cost them less money," Barash said.
As Ku attests, focusing on prevention and intervention requires more empathy for patients and forces physicians to consider how to move solutions further upstream. “It requires me to leave my comfort zone at the hospital and to engage with local grassroots organizations who don't necessarily do healthcare and start engaging with patients where they live in the community," Ku said.
Rod Moore is a frequent contributor to athenahealth's Knowledge Hub.