The social determinants of health: Too long neglected as drivers of health outcomes
A watershed change in healthcare documentation occurred on January 1, 2021. For the first time in 24 years, the Center for Medicare and Medicaid Services (CMMS) created the opportunity to recognize and get paid for documenting the presence of health disparities into the national healthcare billing system.
Specifically, the acknowledgement of “diagnosis or treatment significantly limited by social determinants of health” is now official!
What are the social determinants of health? The Centers for Disease Control and Prevention (CDC) definition of the social determinants of health (SDoH) is “life enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care whose distribution across populations effectively determines length and quality of life.” The addition of SDoH into the payment revisions for 2021 can have a big impact on the health of specific population groups, disease management and every person’s well- being. A zip code’s influence on the health of those living there is multifold.
Where you live directly affects your health in a number of ways, from exposure to air pollution and toxins to accessibility of healthy food, green space and medical care.
I have practiced family medicine in my community for 34 years and yet I never specifically inquired of my patients about these daily life circumstances. I was too focused on following the traditional standards of care for managing chronic diseases and entirely missing and ignoring causes and aggravating factors. In other words: “missing the forest for the trees.”
Not only do we have much of the data already, from organizations like DataHaven, we can easily and quickly collect it from individuals seen in any medical setting, if only all healthcare organizations would make the effort. Collecting the data is step 1 and acting on identified needs is step 2.
I hope no one would argue with the proverb that “an ounce of prevention is worth a pound of cure.” For example, supply a pediatric asthma patient with an air conditioner or continue to pay for repeated emergency room visits? Help a diabetic patient with healthy food access or accept loss of limb, vision or kidney function? We need to deploy a workforce, ideally from the community and charged with operating in the community, “boots on the ground” and work with individuals challenged by social determinants of health to have their needs met. And we have them –community health workers, healthcare social workers and visiting nurses– but the mission is often fragmented and “ad hoc.”
A community health worker is a frontline public health worker who is a trusted member of and has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.
Other workforce personnel, including visiting nurses, healthcare social workers and case/care managers are also active in our state. The problem- -according to the Bureau of Labor Statistics, as of 5/2019 — Connecticut had 330-710 employed community health workers and 2,210 healthcare social workers and an estimated 3,185 RN/LPN’s working in community and public health positions, in the entire state! There are 6,370 RN’s/LPN’s working in home health but by and large they are charged with caring for the clinical needs of post-hospitalized patients in the home and not with identifying and addressing social determinant needs of clients.
There is great need in our state. Bear witness to the following:
- According to the Connecticut Department of Public Health over 280,000 citizens live in “food deserts”– an area, typically urban, where it is difficult to buy affordable or good quality fresh food.
- 16 towns and major cities here have unmet healthcare needs higher than the state index.
- Of the 4,300 hospitalizations for asthma in the state in 2014, 75% were deemed preventable.
According to CT DataHaven:
- Food Insecurity Rate: 13%
- Housing Insecurity Rate :8%
- Transportation Insecurity Ratio: 12%
- Percent of adults without a bank account: 9%
- Percent of working adults underemployed: 15%
The DPH Healthy Homes Initiative (HHI) has defined a healthy home as a home that supports the physical and mental health of the residents. A healthy home promotes good health and quality of life for all individuals and families, including vulnerable populations, such as children, pregnant women, elderly and disabled people.
In Connecticut, according to the 2011 Connecticut home energy assistance program recipient survey:
- 25% said that they went without food for at least one day;
- 29% said that they went without medical or dental care
- 31% said that they did not take their prescription medication
- 12% became sick and needed to go to the doctor or hospital because their home was too cold.
No county in Connecticut has enough affordable housing units to meet the needs of its very low income households.
“The number 1 issue for us is transportation” according to the manager of the State Office of Rural Health. Nine percent of the state population live in rural areas. Rural residents were more likely than their city and suburban counterparts to die from four of the top five causes of death: heart disease, cancer, chronic lower respiratory disease and unintentional injury.
Overall then, at-risk or vulnerable populations include the elderly; residents with incomes below 200% of the federal poverty level; residents in urban core areas, defined as towns with the highest poverty and most dense population; racial or ethnic minorities such as Black non-Hispanics, Hispanics, American Indians, Asians and other non-white groups; residents of rural areas; persons who do not have insurance; homeless populations; non-English speakers; lesbian, gay, bisexual and transgender (LGBTQ) residents and immigrants (these population groups are not mutually exclusive). About 2.9% of the state’s residents, conservatively 104,000, were estimated to be in poor health (U.S. Census Bureau, American Community Survey 2012). Connecticut’s at-risk or vulnerable residents were more likely to be in poor health.
We couldn’t do better than to follow the Roadmap of the National Academies of Science, Engineering and Medicine: Integrating social care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Published in 2019.
1. Design health care delivery to integrate social care into health care, guided by the five health care system activities —awareness, adjustment, assistance, alignment, and advocacy.
AWARENESS should focus on identifying the social risks and assets of specific patients and populations of patients.
Healthcare organizations can pursue a strategy that focuses on ADJUSTING clinical care to address social determinants of health.
Healthcare organizations can pursue strategies to ASSIST patients to connect with social needs to government and community resources.
Healthcare providers can pursue an alignment strategy that ASSESSES the social care assets in the community, organizes those assets to promote teamwork across organizations, and invests in assets to impact health outcomes
Healthcare providers can form alliances with social care organizations to ADVOCATE for policies that promote the creation and distribution of assets or resources to address social determinants of health.
2. Build a workforce to integrate social care into health care delivery.
A recent study by the Perelman School of Medicine at the University of Pennsylvania found a ratio of 55:1 client/staff with social determinant needs generated a return on investment of $2.47 for every $1 spent. In New York state for the nursing home transition-diversion waiver program the client staff ratio is 20-25:1 for serious mental illness/homelessness/substance abuse.
3. Develop a digital infrastructure that is interoperable between health care and social care organizations.
CT HealthLink has finally been launched, to create a health information exchange between different healthcare organizations regardless of their health information systems. Now this needs to be expanded to include the social care organizations. In a recent viewpoint in the CTMirror, the author strongly recommends that all health equity advocates incorporate digital and technological equity into their mission statements and objectives.
4. Finance the integration of health care and social care.
At the end of January, Gov Ned Lamont (D) issued Executive Order No. 5, directing the Office of Health Strategy to establish statewide healthcare cost growth and quality benchmarks and to reach a primary care spending target of 10% by calendar year 2025. Current primary care spending, (the narrow definition of primary care practitioners includes family practice, internal medicine, pediatrics and general practice) was calculated at 3.5% –the lowest among states in the country! The National average was 5.6%. Recently, Connecticut was accepted into the Peterson-Millbank Program– joining Massachusetts, Delaware and Rhode Island– to support efforts on containing healthcare cost growth and improve primary care resourcing.
Executive Order No. 6 includes: Fund, conduct, and translate research and evaluation on the effectiveness and implementation of social care practices in health care settings.
Not happening! Frustratingly sparse attempts to fund and study the deployment of social care interventions to improve healthcare outcomes.
In 2014 according to the Kaiser Family Foundation overall healthcare expenditures in Connecticut totaled $ $35.4 billion! As previously defined, primary care represents 3.6% or nearly $1.3 billion. Per the Governor’s Executive Order this will grow to $3.54 billion by 2025.
The time is NOW to devote these funds to the initiatives defined above. Consistent with this effort is the impetus to pass the Public Option SB 842. We need solutions to meet the moment. The pandemic has profoundly and gravely demonstrated how the social determinant inequities among vulnerable populations resulted in tragic consequences. Taking social risk factors into account is critical to improving both primary prevention and the treatment of acute and chronic illness because social contexts influence the delivery and outcomes of health care.
Howard Selinger M.D. is Chair of the Department of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University. He is also on the faculty of the ECHN Family Medicine Residency program.
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