Addressing Social Determinants of Health in the Bronx NY: A Case Study | Patient Care | AMA STEPS Forward | AMA Ed Hub [Skip to Content]
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Ask patients “what matters to you?” to uncover social determinants of health

When patients are engaged with their health care decisions, it can greatly improve the treatment and outcomes of chronic conditions such as type 2 diabetes and hypertension. Through health coaching, a team-based approach, physicians and their teams can help patients become active participants in their care. One health care collaborative has incorporated health coaching that goes beyond just asking “what's the matter?”

At the Montefiore Hudson Valley Collaborative (MHVC) partner organizations, health coaching means asking, “What matters to you?” MHVC is a network of organizations including hospitals, Federally Qualified Health Centers (FQHCs), primary care providers, skilled nursing facilities, and behavioral health and substance use providers in New York's Hudson Valley. Together, they work to improve outcomes and reduce costs as part of the NY State Delivery System Reform Incentive Payment Program.

Network partners at MHVC committed to begin asking patients in diverse clinical settings, “What matters to you?” (WMTY) to uncover the social determinants of health and identify priority concerns the patient is dealing with. Engagement requires asking what matters, listening attentively to what the patient says and collaboratively designing care plans that address what is most important to the patient.

The AMA's STEPS Forward™ collection of practice improvement strategies offers a health coaching module to guide physicians and their teams. Depending on the state, health coaches can include registered nurses, licensed practical nurses, medical assistants (MA), health educators and community health workers.

Damara Gutnick, MD, an internist and medical director at MHVC, first tried WMTY by asking the question to a few of her patients. She was amazed at how shifting the question from “What's the matter?” to “What matters to you?” opened up the conversation. It also saved her time because she quickly identified the real issues that were most important to her patients.

“It's changing the dialogue and the feeling in the room [when we] think about what we can do together rather than what barriers are getting in the way,” Dr. Gutnick said.

Uncover the patient's needs, goals

Asking, “What matters to you?” helps to connect what is really important to the patient, what the bottom line is and what the driver is for them.

“Asking this question opens up the discussion about what is important to the patient, it allows you to meet them where they're at and incorporate what really matters to them into their care plan,” Dr. Gutnick said.

For example, a patient with poorly controlled diabetes and high blood pressure who is also at risk of losing their housing may not be particularly worried about taking their insulin—they're thinking about where they're going to sleep that night. A “patient-centric” care plan might then include linking the patient to a community-based organization that can help them address their housing needs. Managing the diabetes is of course important, but the priority is addressing what matters to them first.

“You have to recognize that the goal [the patient] might want to set may not be directly related to their medical condition, and look a little bit further at the connections that can be made to other resources to address what is really important to them,” Dr. Gutnick said.

The question goes beyond just asking—it's listening to what patients say and applying it to their care plan.

“If you see a patient in the emergency room and give them seven referrals, chances are they won't follow up with any, but if you give them one that is important to them—and the reason why they came to the emergency room in the first place—you're probably more likely to have them follow up,” she said. “Really think about what it means from the patient's perspective to manage all this work, to manage these referrals and manage their personal life, as well as their health.”

Engage the team, improve workflow

Addressing the patient's concerns begins with team-based care. Implementing health coaching that puts WMTY into practice begins with a passionate person who is ready to perform.

“What is really amazing about this question is you don't need a lot of training to implement it—anybody can ask the question,” Dr. Gutnick said. “It can be the patient care person, the doctor, the care manager or even someone on the phone for pre-visit planning.”

Implementing WMTY does not require significant resources. It may, however, require workflow changes.

For example, a hospital will first engage its staff to see it finds the WMTY approach meaningful and worthwhile. Once the team is on board, it's important to find an appropriate place within the workflow. If the goal is to ask every patient at admission, designate a person to ask the question, distribute the sheets, etc. Whether it's a nurse, an MA or even a physician, ensuring at least one person asks and shares the information learned is important.

“What people have been telling me is once they've started and they see the impact, it's easier to get other colleagues and staff on board—the leadership of organizations we are working with have shared that it's easy to spread the WMTY campaign because staff immediately feel the difference in the dynamics of the conversation when they address “what really matters” to their patients. It brings joy back into work because this is why many of us went into healthcare in the first place,” said Dr. Gutnick.

Physicians and their teams can visit the STEPS Forward module to learn more about health coaching and what it takes to recruit, train and mentor coaches.

Several modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI's Practice Transformation Networks. The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support to enrolled practices by way of STEPS Forward resources. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.

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AMA STEPS Forward™ presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works

Disclaimer: AMA STEPS Forward™ content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward™ content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward™ content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward™ content.

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