Why Physicians Should Embrace Social Determinants of Health

Last Updated: Jul 1, 2021

It’s one of the frustrations of practicing medicine: How can physicians keep patients healthy when much of their health depends on social factors such as poverty, unemployment, lack of education, and addiction?

There’s no question that expanding physicians’ capacity to respond to social determinants of health can benefit patients. But how can physicians have a greater impact when they’re already so strapped for time?

PAMED’s Healthy Communities Project explored this question with leaders in the medical, hospital, and social services communities.

“I don’t think doctors have to lead this effort, but they have to be part of it,” says Theodore Christopher, MD, former PAMED president and an emergency physician in Philadelphia.

Physicians clearly see it as a problem.

According to The Physicians Foundation, almost 90 percent of physicians said their patients had a serious health problem linked to poverty or other social conditions. In The Physicians Foundation’s 2020 Survey of America’s Physicians, 73% percent of physicians indicated that SDOH, such as access to healthy food and safe housing, will drive demand of health care services in 2021.

Technology and a push toward outcomes-based reimbursement models have hospitals and medical practices exploring ways to partner with social services to ensure patients gain the support they need, and physicians can provide more effective care.

COMMUNITY COLLABORATION

Efforts by Penn Medicine Lancaster General Health serve as just one example of how physicians can connect patients experiencing social service needs to organizations with resources to help them.

Physicians at Lancaster General Health ask patients questions related to social isolation, food insecurity, transportation, utilities, and housing. Patients who screened as “high risk” are referred to LG Health’s Care Connections or Ambulatory Complex Care Team, which are multidisciplinary teams of medical and social service professionals.

In the fall of 2018, this concept was expanded for all patients regardless of their risk screening. A Social Service Needs referral was embedded in the electronic health record (EHR) to enable physicians and other providers to seamlessly link patients to social service organizations in the community for navigation.

“People who have one social determinant of health often have others,” says Alice Yoder, Lancaster General Health’s executive director of community health.

Lancaster General Health’s community health department receives the referrals through the EHR, removes private health information, and connects the patient to community navigators.

“We continue to provide care in a way that recognizes complex social issues that are best addressed in partnership with trusted community organizations,” Yoder says. “These partnerships were especially crucial during the pandemic by providing us the ability to continue care for our patients that not only focused on physical health, but also emotional and behavioral health.”

THE BUSINESS CASE

The expanded collaboration between medicine and social services has been driven, in part, by the rise of value-based payment models.

“There’s a tremendous push to keep people out of the hospital and to not have them readmitted,” says Lawrence John, MD, immediate past president of PAMED and a family physician in Pittsburgh. “If you can partner with agencies such as the United Way, they can go out into the home and prepare patients to have a healthy environment, and that will decrease readmissions to the hospital.”

Those incentive figures increase as private and public insurers consider paying for affordable housing, food vouchers to purchase fresh vegetables, and education screenings at doctors’ offices.

A report from the Institute for Medicaid Innovation says challenges remain from inadequate funding and lack of data sharing between medical providers, insurers, and community organizations.

In January 2021, the Centers for Medicare and Medicaid Services issued new guidance to state health officials designed to drive the adoption of strategies that address SDOH in Medicaid and the Children’s Health Insurance Program (CHIP).

TECHNOLOGY DRIVEN

Social services’ ability to identify and connect people to health care services is another important aspect to the social determinants of health movement, says Kimberly Delp, RN, BSN, senior director of Home & Community Based Services at Northern Area Companies/Landmark Home Healthcare Inc. She manages

the lead agency for Meals on Wheels Greater Pittsburgh. Pittsburgh’s Meals on Wheels chapter has written the specifications and utilizes a mobile app that connects those in need to medical professionals. This enables seniors to maintain independence; remain in their own homes; and prevent avoidable hospitalizations, ER visits, and lengthy nursing home admissions.

“We didn’t want to be just about the food,” Delp says. “We wanted to be the eyes and ears of those homebound folks. We wanted to be a part of the overall strategy to reduce health care costs.”

Here is how it works: When volunteers delivering food notice that a homebound client may need medical attention, they press the “Change in Condition” button on their smartphone app as a Health Care Status change.

This alert goes to the intervention specialist RN, who follows up with the client to facilitate medical attention in a timely manner.

In one example, Delp says a meal delivery person noticed one of his regular clients was not walking as he had been in prior visits. The driver used the app to place the “Change in Condition” alert to the intervention specialist. The RN followed up with both the family member and consumer to facilitate timely medical care. In this case, the man was found to have a fractured hip, received the needed medical care, and was able to return to his own home.

ADDRESSING FOOD INSECURITY

Hunger is another major social determinant. In late 2017, the Hospital and Healthsystem Association of Pennsylvania (HAP) partnered with Philadelphia-area hospitals and nonprofits to create a model for identifying patients who suffer from food insecurity.

Seven health systems and 18 hospitals collaborated, says Robert Shipp, vice president of population health strategies at HAP.

Each implemented the two-question screening a little differently. Some did it through the ER. Others did it in an outpatient setting. But the collaboration proved useful, says Shipp, because they learned from one another’s successes and adjustments.

“Clinicians wanted to make sure that they would have the ability to connect their patients to resources when they screened patients,” says Shipp. “Having a path to get someone services is an important first step.”

PHYSICIANS EMBRACE CULTURE SHIFT

Expanding physicians’ capacity to respond to patients’ social needs not only benefits patients. There is early evidence, according to a study by the American Board of Family Medicine, that it could address a major source of stress for primary care physicians at a time when burnout has reached a crisis stage in the profession.

Medical associations, including PAMED, are also starting to embrace the concept. Delegates at PAMED’s 2018 annual House of Delegates meeting voted to support social determinants as a way of providing more comprehensive care. As a first step, PAMED is developing education in the coming year.

Dr. Christopher says it’s a culture shift.

“I think it’s about asking the right questions to a patient,” he says. “It’s about embracing this concept of ‘never discharge.’ In the past, we would discharge and say ‘follow up’ with whomever and just hope they did it.

Now, we have to make the patient aware that we are not releasing them. You are still with us.”

This article was originally written and published in PAMED’s former magazine in the spring of 2020.

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