▶ Health Equity

To mitigate health disparities and achieve health equity, medical practice must extend its reach to the community, and SDOH must be front of mind. However, as the NAM points out, there are many variables to consider. How do we best set priorities when it comes to addressing the SDOH? What are the costs associated with addressing SDOH, and equally important, what are the costs truly associated with failing to address them? Which SDOH have the greatest effect on total population health and well-being, healthcare expenditures, and health equity?^14,15

The problem is complex and has far-reaching consequences, as evidenced by differences of 10–15 years in life expectancy between more affluent and lower-income communities. In large cities like Philadelphia, New York, and Chicago, life expectancy drops from 78 to 63 years based upon economic status, even in neighboring zip codes.^17–19 Healthcare costs and healthcare debt far too often exacerbate income disparities and might lead to poorer health outcomes.^20,21 Being uninsured or underinsured has led many Americans into bankruptcy, exacerbating the link between poverty and health.^22,23 Even with coverage under the Patient Protection and Affordable Care Act (ACA), Americans living at or near the poverty line have less access to care and have higher out-of-pocket expenses for services than their wealthier counterparts. In the United States, far too many people still must choose between paying for prescriptions or medical care and food, housing, or utilities.^24,25

Without consideration of SDOH, the ground gained in the clinical setting can be lost when a patient returns home, leading to costly, stressful, and avoidable treatments and return visits to the hospital.^26–29 According to the Centers for Medicare and Medicaid Services (CMS), one in five Medicare patients return to the hospital within 30 days of discharge. CMS estimates that readmissions costs for Medicare patients is around $26 billion per year, and more than half of that cost can be attributed to potentially preventable rehospitalizations.^30,31 These visits tax hospital systems, impact public health budgets, and compromise the patient’s quality of life on multiple levels.

Despite increased attention to the SDOH, clinical care providers are far too often left “between a rock and a hard place.” They know addressing non-clinical issues is important to their patients, but they often are not prepared—nor do they have the time—to do so in an effective way. While the SDOH have long been embedded in nursing and social work education, medical schools have only recently begun to weave these issues into their tightly packed curricula, leaving the medical workforce lacking skills in this area.^32–36 Results of a 2018 survey conducted by healthcare consulting group Leavitt Partners confirms that while physicians appreciate the importance of non-biomedical determinants of health, most are unsure how to properly address the SDOH, many believe it is beyond the scope of their professional responsibilities and, of course, time is an issue.²⁶

Additionally, providers often fail to appreciate the link between the SDOH, health factors, and health outcomes and are not at the table when policies and programs are developed to improve these outcomes.²⁶ The focus is often on access to care and quality of care. While these are important, they only account for 20% of what matters in terms of impact on health outcomes (FIGURE 3-4). Failure to identify social challenges can lead to inappropriate work-ups, misdiagnosis, discounting of symptoms, inappropriate treatment plans, readmissions, and ultimately poor health outcomes despite access to a provider.^27,31,37,38 For example, treating a patient for chronic pain but failing to identify exposure to violence or recommending that a patient add walking to his or her daily activities without appreciating community-level barriers that may keep him or her housebound can affect short- and long-term health.

The County health rankings and roadmaps show three blocks that are connected from bottom to top reading “Policies and programs, health factors, and health comes.” Health factor is divided into “Health behaviors (30 percent), clinical care (20 percent), social and economic factors (40 percent), and physical environment (10 percent).” Health outcomes are divided into “length of life (50 percent) and quality of life (50 percent).” Health behaviors divided into “Tobacco use, diet and exercise, alcohol and drug use, and Sexual activity,” Clinical care is further divided into “Access to care and quality of care,” Social and economic factors are divided into “Education, Employment, Income, Family and social support, and community safety.” The physical environment is divided into “Air and water quality and Housing and transit.”

FIGURE 3-4 County Health Rankings & Roadmaps.

Reproduced from County Health Rankings & Roadmaps, http://www.countyhealthrankings.org/our-approach (accessed March 28, 2019).

Programs that consider SDOH central to their approach offer the potential to reduce readmission rates and improve patient outcomes. For example, Community-Based Care Management Models are improving outcomes for a small segment of the population (known as “super utilizers”) that account for a large volume of unnecessary emergency room visits.^39–41 These models look beyond the clinical needs of the patients and provide support that addresses their SDOH. Home visits enable the team to explore complex needs and connect patients to important non-clinical resources including utility services, transportation, lead abatement resources, and programs like Meals on Wheels or the Women, Infants and Children (WIC) nutrition program.^39,41–43 The Camden Coalition of Healthcare Providers (Camden Coalition), the first to document the impact of high-intensity care management for super utilizers, is a leader in this space.^39,42–44 The Camden Coalition’s work aligns with the goals of accountable care organizations and has transitioned from a small-scale program to an exemplar of an effective approach to addressing the SDOH. Their model has been duplicated across the nation, and evaluations have shown efficacy.^45,46

Across disciplines and roles, healthcare leaders are increasingly focused on SDOH and employing a range of approaches to address them. HHS has described the SDOH as a key driver of population health and healthcare costs.³ The Centers for Medicare and Medicaid Innovation (CMMI), charged with testing the efficacy of innovative healthcare payment and delivery models, is currently investigating whether systematically screening for and addressing Medicare and Medicaid beneficiaries’ social determinants of health impacts healthcare costs and reduces healthcare utilization.⁴⁷

To enhance providers’ knowledge of patient’s social status to ultimately inform clinical care the NAM recommends structuring electronic health records (EHRs) to support the collection of information regarding social and behavioral factors.^48–50 Private payers and providers, like Optum, have begun implementing innovative social determinants–based information collection strategies to advance their knowledge of their population’s health. The National Association of Community Health Centers has developed an assessment tool called the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), which gauges patient social health status.⁵¹ PRAPARE’s measures focus on actionable conditions and templates exist for several EHR systems, including eClinicalWorks, Epic, GE Centricity, and NextGen.^51,52

While health policymakers and thought leaders are increasingly interested in addressing the SDOH as a means to improve quality of care and reduce healthcare costs, their ability to do so hinges on providers. Providers are well positioned to advance health equity because of their access to the patient population, contextual knowledge of the patient’s medical status, and their role as the “team leader” in the healthcare industry. A new and clearer appreciation of the role of the SDOH has led to a reimagining of healthcare delivery and a call to enhance the provider’s reach. Patient-centered care is critical to the population health response to SDOH and any progress toward health equity.

In patient-centered care, the patient defines his or her health needs and desired health outcomes. Patient goals are the driving force behind all healthcare decisions. Patients become partners with their providers, and providers treat patients not only from a clinical perspective but also from an “emotional, mental, spiritual, social, and financial perspective.”^53–55 This approach should not be reserved solely for the super utilizers discussed above, as there is ground to gain when this lens is applied broadly. Poverty, social isolation, lack of transportation, stress, poor childcare, under-employment, lack of autonomy, power imbalances, and low health literacy can hinder health outcomes for many patients.