How will this module help me understand the impact of social determinants on health and develop an action plan to create a healthier patient population by addressing social determinants?
Eight STEPS to engage your practice in addressing social determinants of health
Answers to commonly asked questions
Key resources to understand the topic, create awareness and facilitate implementation of strategic initiatives
Real examples of how other organizations are addressing social determinants of health
Social determinants of health (SDOH) are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems that shape the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Also known as social and physical determinants of health, they impact a wide range of health, functioning and quality-of-life outcomes.
There are six common domains of SDOH, shown in the chart below:
Economic stability
Neighborhood
Education
Food
Community/social support
Health care system
Historically, the practice of medicine has focused primarily on diagnosing and treating specific clinical conditions. As medical knowledge evolves and our health care system shifts to more value-based and population-focused medicine, the medical community is beginning to take a more comprehensive approach to patient care. Practices are looking beyond the clinic walls to understand how patients' social and physical environment impacts their health. Quiz Ref IDOver two decades of research indicates that SDOH have up to a six-fold greater impact on health than clinical care. Addressing SDOH requires collaboration across multiple sectors, including but not limited to medical care, public health and social service providers.
In 2003, the World Health Organization (WHO) suggested a list of ten SDOH,2 while the CDC and Healthy People 2020 identify five key areas of social determinants.3- 5 Defining a discrete list of SDOH is less important than recognizing that there are interactions among social determinants that create an even greater impact on health than any one social determinant alone. For example, people living in poverty-stricken areas often have issues with education, housing, unemployment and stress. This confluence of negative SDOH and its effect on health status is often reflected in disparities in life expectancy based on zip code.
The profound impact of these factors can persist across generations and drive health inequity based on race, ethnicity, and socioeconomic status, effects that can be visualized on a map of life expectancy—a few miles can translate into a significantly shortened lifespan (Figure 2).
You can explore disparities in life expectancy in other places in the U.S. at https://societyhealth.vcu.edu/work/the-projects/mapping-life-expectancy.html
Not only do social determinants influence health outcomes, they can also have an impact on a practice's clinical outcomes, financial sustainability and resource allocation decisions, as well as on the overall health of communities and the health care system. As the nation moves toward value-based care, expanding our health care focus to include SDOH is increasingly necessary to achieve improved outcomes.
Eight STEPS to engage your practice in addressing social determinants of health
Understand and engage your community
Engage key leadership
Assess your readiness
Select and define your plan
Assess SDOH at the patient level
Link patients to SDOH resources
Evaluate and refine
Celebrate your success
Step 1 Understand and engage your community
Begin by understanding the health needs of the communities you serve. It is likely that you have already seen the impact of SDOH among your patients. In addition to listening to the perceptions of the communities served, there are multiple resources available in every community to learn more about the health of different groups. Quiz Ref IDA good place to start is by reviewing your local Community Health Needs Assessment (CHNA). Federally tax-exempt hospitals are required to conduct a CHNA every three years. Hospitals conduct a CHNA in collaboration with local public health departments along with community input. This report is posted on the website of each hospital and includes information about the population that the hospital serves, identifies disparities, and prioritizes health issues of concern. If you are in a community practice with patients seeking care across multiple hospitals, it may make sense to sample a few CHNA reports to further define the needs of your patient population. The assessment can be easily accessed online by typing your organization's name and “Community Health Needs Assessment” into a search engine.
Example: Rush University Community Health Needs Assessment
Step 2 Engage key leadership
Addressing SDOH is an essential strategy to improve the health of a population. Support from key leadership, such as a Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), and Chief Medical Information Officer (CMIO), is recommended. Key leadership provides the necessary financial and staffing resources needed to implement programs and initiatives. They can also assist in removing any administrative or logistical barriers. For a smaller scope of intervention, such as an individual department within a larger institution, secure the support of the department Chair or for an individual practice, the practice manger.
Many practices and health systems have seen the positive impact of addressing SDOH, both financially and in terms of patient health outcomes.
Houston's Patient Care Intervention Center (PCIC) focused on 39 patients who had at least ten emergency room visits or four hospital admissions over the previous year. With an emphasis on care coordination, these patients received social assistance, a chaperone at primary care appointments and additional focused interventions. Over the course of six months, the total health care costs of the 39 patients were reduced by $1.3 million dollars (Figure 3).
By sharing success stories from other practices and linking the needs of your community to the health of the organization, you will be better equipped to make the business case for assessing SDOH to key leadership.
Step 3 Assess your readiness
Before selecting a specific initiative, assess your organization's readiness to implement.
Step 4 Select and define your plan
Quiz Ref IDThere are many SDOH and each can influence one another. However, it is best to begin by selecting one area of focus for your SDOH initiative.
Select a social determinant
Choose a health outcome to track
Define your target patient population
Consider what type of practice setting best describes your clinical practice.
The practice setting will play a key role in determining the size and scope of project implementation. Will you deploy a system-wide initiative or begin with a subset of your patient population?
There are many ways to address a SDOH, depending on the size and capacity of the organization. For example, a small practice might screen for a SDOH and refer patients to community organizations for assistance. A larger practice might employ a social worker to navigate the community referrals with patients. A larger organization, such as a hospital or academic medical center, might screen, refer, navigate, develop new services if there are gaps in the community (e.g., patient education activities and farmer's markets for access to fruits and vegetables), and contribute to community policy considerations, for example, supporting local parks and neighborhoods to combat physical inactivity and smoke-free campuses throughout the community.
Below is an example of a quality matrix, which can help you identify different potential initiatives for a specific population and SDOH, based on level of intervention and level of prevention.
As you define your plan, leverage quality improvement methods, such as Plan-Do-Study-Act (PDSA) or Lean concepts.
Identify who will be on your SDOH team
Downloadable tool: Workflow Implementation Guide - NAHC
Orient practice staff to metrics and goals
Map out your workflows and what roles each team member will play
Identify and communicate your plan with your community partners and resources
Step 5 Assess SDOH at the patient level
Once you have resources to address needs, start to assess a portion of your patient population for the selected SDOH at an individual patient level. This is recommended regardless of the practice setting or social determinant selected. Quiz Ref IDBy implementing a screening process into your workflow, you will quickly begin to understand what is important to the patient and identify social determinants that may be impacting their health status.
Step 6 Link patients to SDOH resources
Quiz Ref IDOnce you have identified patients who have screened positive for your selected SDOH need, the goal is to link the patient to appropriate resources. Providing the patient with a list of resources can be beneficial, but taking a more active role in arranging a resource alongside the patient and following-up to ensure benefits were accessed is likely to have a much larger impact. Examples of SDOH resource connections might include:
Referrals to local food banks and food pharmacies
Vouchers for bus and subway transportation
Providing a mobile food pantry at a clinic location
It is important to think about how this “navigation” could be accomplished in the practice setting. There are models using students (Health Leads and Case Western Reserve University's Patient Navigator Program) and community health workers as parts of the medical team to extend the reach of physicians and nurses.
Take advantage of the 211 – Essential Community Services Program. By simply dialing “211”, callers are routed to referral specialists who can help match individuals to available resources and oftentimes will make a direct referral to an organization that can provide assistance. This resource is available throughout the country.
Step 7 Evaluate and refine
Throughout the implementation phase of your SDOH initiative, it is important to refine and enhance your workflows. Discuss with your team and patients to learn what is working and what needs to change. If you discover that your screening method isn't occurring as consistently as it should, examine the process to see if you can identify a better way to screen more patients. The solution may be as simple as training one extra staff member on administering the questionnaire during rooming.
Step 8 Celebrate your success
As you continue to refine your workflow, celebrate your successes. Share patient stories and best practices with colleagues across your organization and community. By sharing your stories, you may inspire other practices to implement your model, which will help to scale and sustain the initiative, as well as improve the health outcomes of many more patients across the community.
With a step-wise approach, healthcare professionals and systems can address SDOH in order to improve health outcomes, improve care quality, lower costs and enhance joy at work for health care providers across the organization. As hospitals and clinics expand their role in creating healthy communities, it will be essential to address the SDOH for their patients where they live, work and play.