Embracing Social Determinants of Health


In a 2018 national survey by the Physicians Foundation, 88 percent of physicians reported that some, many, or all of their patients are affected by social determinants that represent serious barriers to their health.

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.

But how can physicians have a greater impact when they’re already so strapped for time?

  • Community Collaboration

    sdoh1Photo: used with permission from Penn Medicine Lancaster General Health

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

    Physicians at LG 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, LG Health’s Executive Director of Community Health.

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

    We are providing care in a way that recognizes complex social issues that are best addressed in partnership with trusted community organizations.” Yoder says.

  • 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, president-elect at 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 incentives figure to 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.

    However, the Centers for Medicare and Medicaid Services issued guidance in 2018 that would allow private Medicare plans to provide a broader range of benefits beyond the typical medical-related services, and a law that Congress passed in 2017 would expand those supplemental benefits in 2020.

  • 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 healthcare 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 smart phone 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 states 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 non-profits 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 out-patient setting. But the collaboration proved useful, says Shipp, because they learned from each other’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.”

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