Consider this scenario.
A middle-aged man with a history of type 2 diabetes has been feeling weak and disoriented. He checks himself into the hospital because he believes his blood sugar is out of whack. Sure enough, it is. His care team runs some tests, reviews the medications he is taking, and makes adjustments to get his blood sugar back under control. Patient treated. Problem solved. Right?
Not so fast.
What the health care team treating this patient doesn’t know is that he recently lost his job. Feeling stressed to find a new job, he discontinues following the healthier habits he has developed, stops exercising, and begins to eat more fast food.
What would his care team at the hospital do differently if they had known the situation? Would they have made adjustments to his medications? Provided a referral for mental health services? Given vouchers to a local food bank with healthy food options? Would they have set different expectations for his next visit and a different treatment plan? It’s likely they would have.
Welcome to the world of the social determinants of health. Social determinants refer to any aspect of a patient’s life that can impact the care received and their likelihood to benefit from that care.
“Social determinants are being discussed within health care with much greater depth and intensity than ever before,” says Christopher Holliday, PhD, MPH, director of the Population Health & Clinical-Community Linkages for the American Medical Association. “In essence, social determinants provide health care providers with much needed insight into why a patient may not be following a treatment plan or medication regimen as recommended. Health care providers are able to shape the care provided in a very targeted way because of what they understand about a patient’s lived experience. For example, screening for social determinants can help a care team know if a patient has housing insecurity or transportation issues that impact their ability to take or obtain prescribed medications. Health care providers can use knowledge of the social needs in their patients’ environments to help them have the best possible chance at achieving desired treatment outcomes.”
According to Holliday, who also serves on Capella University’s School of Nursing and Health Sciences Advisory Board, screening for the social determinants of health has grown significantly among health care providers since the Affordable Care Act (ACA) became law. The ACA has changed the way the government (Medicare) pays for health care services; the traditional fee-for-service model is shifting to a value-based model. In other words, health care providers (e.g., hospitals and clinics) reimbursing based on how many services are provided, or for how long they treat a patient, is becoming a thing of the past. Rather, providers receive a set amount for the care required for a quality health outcome. This payment structure incentivizes providers to deliver care in an efficient way that takes into account the social and contextual needs of patients.
“To provide patient-centered care as efficiently and effectively as possible, today’s health care provider needs to know so much more about the patient,” Holliday explains. “By knowing the whole person, the provider is empowered to develop treatment plans that are individualized to the patient’s specific needs and challenges.”
Ask Those Probing Questions
So how do you uncover social determinants that could be affecting a patient’s health? It starts with having a deeper conversation, including full disclosure regarding why certain questions are being asked, and with sensitivity and empathy for what could be difficult topics to discuss.
“Health care teams simply have to ask those in-depth, probing questions,” Holliday says. “Providers can’t just treat the presenting issue. That’s no longer enough. It never was. They have an added duty now to understand and react to the underlying factors that are impacting patients’ health.”
For example, Holliday says a patient may be eating cereal for breakfast, lunch, and dinner because they can’t afford anything else. Or the patient may not drive and doesn’t feel safe walking to the clinic where they receive rehabilitation. Those are key factors that directly impact a patient’s overall health that must be understood as part of care.
There are several tools now available to help health care providers capture and track the information they need. Those include:
- The Patient Centered Assessment Method (PCAM), which assesses a patient’s lifestyle behaviors, mental well-being, social environment, health literacy, and communication and care coordination needs.
- The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Implementation and Action Toolkit, which consists of a set of national core measures as well as a set of optional measures for community priorities.
- Expanded electronic health records fields, which allow for the better capture of social determinants.
Begin With Leadership
For health care providers to be successful in exploring social determinants, they need the explicit support and encouragement of the organizations that employ them. The questions that need to be asked to uncover social needs can be very personal. The entire care team must be on board and understand the need for taking such an approach.
“This needs to be as much a top-down shift in the care approach as it is bottom up,” Holliday says. “Health care organizations not only need to encourage their staff to understand the bigger picture of their patients’ lives, but they also must build relationships with community-based resources – think local YMCAs, food banks, affordable housing providers, mass transit operators – to help patients achieve the full benefit of their medical care. It can’t all be done in the health care setting.”
Let the Community Know What to Expect
To avoid any awkwardness or reluctance among patients to share the more intimate aspects of their lives, it is important that health care organizations proactively educate the broader community as to what they are doing and why. It is important to market the fact that having discussions about social determinants is a good thing and in the patient’s best interest.
“Patients should not be surprised by questions that explore social needs,” Holliday says. “Rather, they should be well-informed in advance that their health care team wants to treat them as a whole person and truly understand the full context of their lives. You want them to be as open and forthcoming as possible and feel safe in doing so. There can’t be any hesitation that they will be judged or somehow punished because of what they share.”
Beyond being helpful in delivering the best possible care, the use of social determinants aligns with the Hippocratic Oath that health care providers swear to uphold.
“Simply put, this is the right thing to do,” Holliday concludes. “Our culture, particularly in health care, is shifting to one of more holistic care that acknowledges what’s happening in patients’ lives. Understanding that full context is becoming core to health care delivery.”
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