Improving Health Equity by Understanding the Social Drivers of Health
How many times have we heard that proper nutrition, daily exercise, self-care, sleep, and regular check-ups with our doctors are fundamental to good health? Well, there are other, maybe more important, factors at play that can impact an individual’s well-being, which are the realities of their everyday life or social environment.
These factors are called social drivers of health or social determinants of health. What are these social drivers of health, exactly? According to the U.S. Department of Health and Human Services, “social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These are conditions typically outside of an individual’s control. They include where a person lives, as well as their education, job, social circles, and access to transportation, food, and healthcare.
Patients with socioeconomic needs and patients from underserved communities are hit the hardest by social drivers of health. They often involve more than just telling someone to eat more vegetables, get more exercise, or take a pill. To improve health equity, providers need to screen for and address patients’ social drivers of health and make a plan to help assist patients with these barriers to health.
Screening for Social Drivers of Health
Screening for social drivers of health seems straightforward on the surface. It is just a matter of asking patients about their social and economic conditions. Providers can screen individuals via face-to-face discussions or self-assessments to avoid potentially inferring the “correct” answer. However, these are uncomfortable questions to ask, and there is no guarantee that patients will be forthcoming in their responses. It can be difficult for patients to share details about their finances, safety, and abilities. Due to these reasons, a standardized, proven tool should always be used for screening.
When someone is transparent and truthful, providers must be ready for the next steps. What are the patient’s viable options? What solutions are readily available? What workflows need to be established to provide the necessary intervention and close the loop on referrals? What is the strategy for helping patients overcome their individual social drivers of health? If health systems do not follow up on these screenings, they will miss opportunities to truly impact that person’s health for the long term.
This may be difficult for a health system to get off the ground, and they could meet resistance from providers who are spread thin or uncomfortable engaging with individuals at this level. These interventions must encompass the “health system,” not just the providers. It takes planning to identify the best workflows and have the appropriate interventions established in common drives, as well as implement tracking pieces to execute effective screening and assist with positive results.
The reality is that providers must understand patients’ social drivers of health to properly treat and develop plans of care that meet their needs. When a health system initially starts screening for social drivers of health and capturing the data, it will likely find unidentified health inequities among certain patient communities. Currently, healthcare is continuing to tackle medical conditions in the same ways they have for years. It is time to change the paradigm and consider how social drivers of health affect care and health management.
Correcting Health Inequities Using Data
Correcting health inequities starts with collecting data at the patient level. This requires a proven electronic screening tool that can gather information in a routine fashion and aggregate to the population level for analysis. It is the best means to make sense of the data and determine where any patterns emerge. Those patterns will clue a health system into what might need to be addressed for a given patient population. Because social drivers of health are determined partly by shared environmental conditions, there will likely be common health inequities.
Most importantly, the electronic system must track and capture the interventions. If a tool identifies a patient’s driver, for example, the health system must respond in kind to detail how it will ensure the individual receives the appropriate resources through tracking and closing the loop workflows. Once this information is compiled, it can reveal patterns at the patient and community levels. The most effective systems review and consider the population-level data. For instance, the data could highlight why certain gaps in care seem difficult to achieve. This might lead to creative thinking, which could spur the development of new interventions that address the deficiencies at a neighborhood level.
However, it isn’t just the data derived from screening for social drivers of health that will move the needle toward health equity. Going through the process can encourage healthcare providers to think differently about patient communities, especially more vulnerable populations. A different mindset can be a significant force for change and help move health systems away from practices that result in poor health outcomes.
Social drivers of health are engrained into society. To improve health equity and outcomes, systems must begin factoring in these drivers when developing plans for care. Capture the information, analyze the data, and identify the patterns that have contributed to inequities. Only then can a provider truly serve its patient population and improve the health of its local community.
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Jeanette Ball, BSN RN, PCMH CCE
Solution Architect, Health Solutions
Jeanette Ball, Client Solution Executive for Population Health and Value-Based Care at CTG, brings an extensive clinical, population health, and healthcare administrative background to CTG. As a senior consultant, and Registered Nurse, Ms. Ball has more than 30 years of experience in the healthcare industry, including a 10-year history of outpatient medical center executive administration, and more than 13 years as a senior consultant in clinical application design, population health strategies, and overall health system preparation for responding to health care reform and value based care. Ms. Ball demonstrates knowledge and experience supporting the integration of IT solutions with medical care delivery, specializing in Patient Centered Medical Home (PCMH) recognition, population health, workflow analysis, process redesign, FQHC and CAH speciality, provider clinician adoption, and quality redesign. During her tenure at CTG, Ms. Ball has worked on groundbreaking RHIO development, and has assisted dozens of ambulatory practices with PCMH recognition, and practice workflow efficiencies for improving health outcomes. She is a NCQA PCMH Certified Content Expert, receiving her recognition in May 2013, as one of the first 100 PCMH certified content experts in the nation.
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