There is increasing understanding that social determinants — ranging from poverty and illiteracy to unstable housing and lack of transportation to domestic violence — create tangible barriers to wellness. Even when healthcare providers do everything right in terms of accurate medical diagnoses, proven care plans and effective care coordination, social determinants inhibit a patient’s ability to pursue and reach treatment goals.

During the past five years, the spotlight has shifted to improving the experience of care, improving the health of populations, and reducing the per capita cost of healthcare – the so-called Triple Aim. All of these efforts have fallen short in accounting for the true impact of social determinants in. Though social workers have been heralding this message for years, only recently have other healthcare stakeholders recognized the need for integrated behavioral health in specialty care been recognized – a good first step and real progress.

What are Social Determinants of Health?

The CDC defines social determinants of health (SDOH) as “conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes.” Research confirms that SDOH contribute to an elevated burden of disease in children, as well as to increased risk and severity for heart disease and stroke. Further, factors such as race and/or ethnicity and household income are predictors of unplanned pediatric surgical readmissions (see also Auger, Simon et al and Nakamura, Toomey et al).

Collecting Social Determinants: What Healthcare Organizations Can Do

There are several proven instruments for gathering SDOH, including:

  • The Patient Centered Assessment Method (PCAM) assesses patient’s lifestyles and behaviors, mental state, social environment, health literacy as well as communication and care coordination needs. Care managers and care coordinators often use PCAM. Initial validation studies are promising.
  • The EveryONE Project SDOH Screening Tool has a long and short form and is available in Cordata’s care coordination product.

Social Determinants Plans in Action

Leading healthcare organizations social determinants on their radar, as was clear from many presentations at the 2018 JP Morgan Healthcare Conference:

“As Intermountain shared: “Zip code is more important than genetic code.” To that end, Geisinger refers to their focus on “ZNA.” They have deployed community health assistants, non-licensed workers who work on social determinants of health and have implemented a “Fresh Food Farmacy,” yielding a 20 percent decrease in hemoglobin A1c levels along with a 78 percent decrease in cost. Organizations like ProMedica Health System in Ohio have seen similar results with their focus on hunger in Toledo. WakeMed has an initiative focused on vulnerable populations in underserved communities that has resulted in a significant decrease in ER visits and admissions and over $6 million in savings.”

It’s important to note that in 2014 the Institute of Medicine (IOM) recommended that 12 social determinants be included in all electronic health records as part of Meaningful Use 3.

Again, all this is progress. Social determinants are significant barriers to care and must be managed more effectively than in the past if patients are to achieve treatment goals and if healthcare organizations are to achieve quality clinical and financial outcomes.