Social determinants of health (SDOH) are entering the healthcare conversation more often these days for a reason. According to the World Health Organization (WHO), numerous studies report that SDOH play a role in 30% – 55% of health outcomes. In fact, research has indicated that social determinants may be more important to an individual’s health than their lifestyle choices.
It’s no question that addressing socioeconomic factors is crucial to the goal of achieving health equity, but how can health systems effectively collect this data when issues like poverty are hard for patients to discuss? And how are these data points used to drive further action in the care management space? My goal is to help providers and stakeholders answer these questions to improve patient outreach and bridge the gap between care and health inequity.
How to Identify the Social Determinants of Health
Social determinants of health are broken up into five categories:
- Economic stability: Income, transportation, ability to pay for medications, and food stability
- Education: Employment, enrollment in higher education, and early childhood development
- Medical care access: Health literacy and access to primary care
- Living environment: Housing stability, environmental conditions, and quality of housing
- Social inclusion: Racism, discrimination, and incarceration
These factors can influence a person’s health in positive and negative ways, creating disparities and inequities in care. With health equity being a goal for the healthcare industry, the factors that impact disadvantaged populations need to be addressed.
However, for SDOH to be addressed, they must first be identified within a population.
The PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) form is a great resource to collect this data from patients in both office and at-home settings. The PRAPARE screening tool is available in over twenty-five languages, making it accessible for individuals who speak many different languages. The information that is on the form includes question about housing, safety, income, food security, and emotional health.
How to Address SDOH in a Community
There is no one-size-fits-all solution to addressing SDOH within a community. But there can be initiatives put in place that enhance healthcare accessibility to people who are unable to travel to a physician’s office as needed. This is where community health workers come in.
Community health workers (CHWs) serve a similar function to patient navigators or case managers. They act as a liaison between providers and hard-to-reach patients to ensure these patients receive the care they need to properly manage their health. CHWs have deep ties to the individuals they manage because they are culturally and linguistically tied to the community in which they work. They are able to have effective and meaningful dialogue with patients about their lives and barriers to care in ways that physicians or other providers can’t.
CHWs are essential to bridge some of the gaps between providers and inaccessible, at-risk patients, such as administering the PRAPARE screening or aiding in routine medication adherence.
Using Technology and Data to Drive Action and Healthcare Transformation
Collecting necessary patient data is only the first step in the process of addressing social determinants of health. Once you have all the details you need about your patients, their health, and other factors, that information must be properly managed. Technology plays a crucial role in making ease of data management possible.
Recently, I presented alongside Primary Partners and Alliance for Community Health at the RISE Summit on Social Determinants. In our presentation, we outlined the Alliance for Community Health program and how this initiative used Lightbeam to assist with data analytics, workflow optimization, and engaging providers. Using population health management, Primary Partners and the Alliance for Community Health was able to identify and integrate opportunities into practice-friendly front-ends to alert and close HCC, utilization, and care gaps.
The Alliance for Community Health now shares clinical care plans and high-risk patient engagement information with the community health workers who are assigned to co-manage patients. Co-management with the aid of a community health worker helps extend a provider’s reach beyond traditional office and telemedicine visit; CHWs are able to bring medical care directly to the patient’s community and home. Thorough their community health workers, patients have access to a variety of additional community resources, which include transportation, social engagement, and food, as well as telemedicine support for those facing technology challenges.
For more information about clinical transformation integrating SDOH into your population health strategy, I encourage you to read through our blog and visit the Lightbeam Education Center.
By Jessica Scruton, BSN, RN, CCM-R
VP of Clinical Transformation