When it comes to gathering and assessing social determinants of health (SDoH) as part of a medically appropriate history and examination, it is necessary to employ 5 key strategies, said Allysceaeioun D. Britt, PhD, MPH, Interim Vice President, Office of Faculty Affairs and Development, Meharry Medical College, Nashville, TN, in a presentation during the virtual 2020 Healthcare Administration Alliance Conference.
According to Dr Britt, these 5 strategies are essential to improving patient outcomes, and include defining and understanding SDoH, creating a culture of health equity to better address SDoH, expanding screening opportunities to reduce missed opportunities when engaging patients, enlisting community-based resources to help support engagement efforts, and measuring success to ensure the achievement of necessary goals.
“As the cost of healthcare steadily increases, and resources—both human and fiscal—continue to diminish and become strained, it is important to be efficient in your work to reduce cost, improve impact, and ideally achieve optimal health outcomes for your patients and members,” she said.
Dr Britt discussed these strategies in detail, and armed providers with the know-how to properly gather and assess SDoH in their practices.
Dr Britt explained that it may be confusing to providers when patients have been given optimal care but fail to improve.
“To provide optimal health outcomes we must first look at what factors truly influence or determine one’s health,” she said. The 5 categories of determinants of health are genetics, behavior, environmental and physical influences, medical care, and social factors.
Social factors, she noted, have the greatest impact on health outcomes. SDoH encompasses economic and social conditions, and are shaped by the amount of power, money, and resources that one may have, all of which are influenced by socioeconomic and political factors, such as policies, culture, and societal values.
Numerous studies suggest that SDoH accounts for between 30% and 55% of health outcomes, whereas other research points to specific determinants that contribute to mortality, including neighborhood and physical environment, low socioeconomic status, poverty, and income inequality.
Historically, addressing SDoH has been a challenge in the healthcare system, largely due to the lack of a standardized screening tool in the electronic health record, reliance on clinical provider staff to screen and document for SDoH (not to mention the challenges associated with retrieving that information from the source), and the lack of a standardized crosswalk between SDoH and diagnostic codes for documentation.
“International Classification of Diseases, 10th Revision (ICD-10) codes provide more than specific diagnoses, and as a result, greater opportunities to document and detail both medical and social risk. For example, the ICD-10 code for food insecurity is Z59.4,” Dr Britt explained. “Providers must screen for and document these items in a patient’s record, but they also must be able to analyze that data.”
According to Dr Britt, 5 steps should be employed to create health equity within an organization: understanding the communities in which patients live, learning how SDoH works, addressing implicit bias, empowering the healthcare team, and improving health literacy. However, providers should also keep in mind that people may not be able to directly change circumstances, such as where they live, their employment, or their lack of employment.
“You may say, ‘I’m the payer; I just ensure that they have the health network that allows them to receive their benefits,’ or, ‘I’m the provider; I just ensure they receive good medical help and support when they come see me,’” she noted. “But understanding social determinants of health and what they mean to health outcomes is essential to helping move a patient forward toward health equity.”
The final 3 steps toward health equity build upon each other, starting with recognizing implicit bias within an organization and addressing those underlying attitudes and stereotypes that people hold toward members of another group.
“Implicit bias is common in society, and in healthcare, it can have a serious impact on the quality of health provided,” Dr Britt said. “Acknowledging and responding to implicit bias can be difficult, but it needs attention.” Implicit bias cannot be measured through self-reporting, but instruments such as the Implicit Association Test (www.implicit.harvard.edu/implicit) can help.
Addressing this specific type of bias will empower the healthcare team to become more culturally competent, so they can improve health literacy among their patients and members. This requires a culturally proficient team and linguistically appropriate written materials (ie, plain language instead of medical jargon, visual aids, using the “teach-back” method), as the latter has a significant impact on the degree to which patients or members have the capacity to obtain, process, and understand the basic health information being shared with them. This is referred to as “health literacy.”
According to Dr Britt, providers should ask themselves what barriers their patients face to living a healthy life, and what resources they have access to in their communities. Understanding these factors creates a strong collaboration and can illuminate issues that patients or members may not even know they’re facing.
“You may have heard the catchphrase, ‘your zip code matters more than your genetic code,’” she said. “The reason is that poor health outcomes tend to cluster in disadvantaged neighborhoods.”
Some of these living conditions may be obvious, such as income inequality or high unemployment, but others may be less apparent, such as environmental factors. Expanding collaboration with state or local Departments of Health allows for a better understanding of what is occurring in these communities, and tools, such as the annual County Health Rankings (www.countyhealthrankings.org), measure vital health factors such as smoking and obesity rates, high school graduation rates, and income inequality.
The third strategy focuses on reducing missed opportunities. “Information on social determinants of health can be used to identify and develop a wider scope of quality improvement activities for patients and members,” Dr Britt said.
In the provider role, this involves taking action to incorporate screening for SDoH into multiple areas of a patient visit, from the moment the patient walks in the door to the moment they leave. When a patient checks in, posters in the waiting room can serve to prompt a discussion about their social needs; while the patient sits in the waiting room, an SDoH screening tool can be distributed to patients. Other methods may include expanding the vital signs to include SDoH and recording referrals to community-based resources (as well as outcomes after follow-up) in the electronic health record. On the payer side, expanding screening opportunities might involve educating providers on extracting relevant patient information (for those who may not use an electronic health record).
“The addition of a screening tool to be used at check-in should—at a minimum—ask about housing, food, and safety,” Dr Britt explained. “These physiological and safety needs are the foundation of an individual’s well-being, and can be the starting point for the provider, or even the payer, to change health outcomes.” As with clinical assessment tools, providers can use the results of these screening tools to inform treatment plans and make referrals to community resources.
“Expanding collaboration to include the community in which patients and members live is essential,” she said. “Local Departments of Health are often key at a local level, as they have strong relationships with various community-based resources.”
The National Association of County and City Health Officials has a directory of local health departments (naccho.org), whereas other organizations, such as 2-1-1 (www.211.org) and Aunt Bertha (www.auntbertha.com), can also be invaluable to identifying local resources.
“The final strategy, measuring success, is critical to continuous quality improvement,” said Dr Britt. “There must be continuous quality-improvement activities at both the payer and the provider level, and payers must work with providers to be clear on what is expected and what to report.”
Simple measures, such as percent of staff trained and percent of patients who receive follow-up, can go a long way, and can be the first step in creating health equity, she concluded.
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