Providing safe, efficient and high-quality care is the goal of every clinician. But as the healthcare system shifts away from fee-for-service toward a model based on value and population health, there’s growing awareness that factors such as where patients live, whether they regularly encounter violence and whether they can afford healthy food have a far greater impact on their health outcomes than what happens within the four walls of a medical practice.
These environmental, economic and social factors are known as social determinants of health. They include safe housing, strong social support networks, transportation, education levels, income, access to healthcare and employment. An increasing body of research shows that social determinants of health play a pivotal role in patients’ morbidity, mortality, life expectancy and healthcare costs.
In a 2015 report, the Kaiser Family Foundation said although healthcare is essential to health, it’s “a relatively weak health determinant” especially when compared with the impacts of patient behaviors, such as smoking and exercise. According to the report, social determinants of health fundamentally shape patients’ “opportunities and barriers to engage in healthy behaviors.”
In fact, research cited in the report shows that factors such as poverty, education and weak social supports account for a third of total deaths in the U.S. annually.
Value-based payment models, such as accountable care organizations, often emphasize the importance of non-clinical interventions, especially for high-risk patients with multiple, chronic illnesses. In a June 2017 post on the Health Affairs Blog, former U.S. Sens. Tom Daschle and Bill Frist named meal delivery, supportive housing and transportation to medical appointments as just a few of seemingly simple interventions that can lead to dramatic improvements in health outcomes for complex patients, and they called for payment models that incentivize those options.
But efforts to assess social determinants of care in a medical practice setting have been stymied by reimbursement structures that don’t support non-clinical interventions and by challenges in collecting and analyzing the data.
In an editorial in the Annals of Family Medicine entitled, “Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health into Primary Care Practice,” the authors argued that the ability to act on social determinants of health “in medical care settings in a meaningful, systematic way has been constrained by a fee-for-service payment structure, a medical culture focused on treating disease rather than promoting health, and limited technologies, among other barriers.”
The good news, according to the editorial’s authors, is that innovative delivery models such as the patient-centered medical home, and the prevalence of team-based care are helping providers address social determinants of health. And advances in technology are making it easier to collect data on social supports, alcohol use, hunger, intimate partner violence, stress and other social determinants of health in an automated, standardized way.
“(T)echnological advances have made it possible to better integrate SDH data into electronic health records (EHRs), facilitate primary care teams’ efforts to address patients’ SDH, and enable teams to coordinate community service referrals and other SDH-related actions,” they wrote.
