Social Determinants of Health

This article was written by Jim Cagliostro.

Social determinants of health (SDOH) are defined as “conditions in the environments in which 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.” (HealthyPeople.gov).

The “band-aid” solutions in US healthcare

We have all no doubt heard the term “band-aid solution,” a phrase often used to describe a temporary solution that fails to address an underlying cause or prevent it from worsening. It conveys the idea of placing a bandage on a bleeding wound so the problem can no longer be seen even if the bleeding continues.

So-called “band-aid solutions” for the human body often result in more complicated health issues together with longer recovery times.

Despite the apparent short-sightedness of these temporary fixes, we have adopted a similar approach with population health in this country.

The majority of people measure the success of a nation’s healthcare system by what is accomplished within the context of their local hospital or doctor’s office, but there is so much more that influences an individual’s health.

Healthcare in the USA has a reputation for being one of the most advanced in the world, and yet repeated studies show that the health of American people does not measure up to other high-income countries.

As a nation, we also spend more per capita on healthcare than any other country[1]. But we have failed to promote healthy living and address the underlying conditions that lead to the disease and illness that plagues American health today. By 2030, it’s predicted that 171 million Americans will have some form of chronic disease[2].

What role do social determinants of health play in chronic disease?

While genetics play a role in an individual’s health, the impact of environment and lifestyle choices must also be considered. Many common illnesses such as heart disease, diabetes, and certain types of cancer can develop as a result of environmental and lifestyle factors, regardless of genetic makeup.

While genetics influence an individual’s risk of becoming ill, the development of a disease is greatly affected by their social determinants of health.

The ‘nature versus nurture’ debate is not new but one thing cannot be refuted: the US healthcare system has not (yet) discovered a way to change our genetics.

That said, there are certain steps that can and should be taken to improve the conditions in which individuals live.

Conditions often considered social determinants of health include, but are not limited to:

• Access to healthy food and safe housing.
• Education and literacy.
• Socioeconomic status.
• Employment.
• Social support networks.
• Access to health care services.
• Transportation.
• Neighborhood and physical environment.

Why are SDOH so important in healthcare?

In any society, these conditions can vary depending on location.

The environment in which people live, learn, work, and play has a tremendous impact on health outcomes. For instance, the availability of food and safe housing are essential for survival. But accessibility can vary depending on an individual’s living circumstances and have a deep impact on their health.

Research shows that people with a higher income and better educational opportunities have lower rates of chronic disease[3].

Low incomes can lead to limited employment opportunities which, in turn, can make it difficult to maintain health insurance as most families have access to insurance through their employer.

Furthermore, some counties have multiple healthcare services to choose from while rural locations may suffer from a lack of transportation and healthcare options.

Many hospitals fall short in recognizing the impact of these social determinants. As a cardiac nurse for much of my career, I have frequently cared for patients with congestive heart failure (CHF) who would attend the hospital with a CHF exacerbation.

After a few days of receiving medical treatment, proper nutrition, and education in the hospital, the patient would be discharged home only to return a few days later.

These patients were often returning to a home environment that was not conducive to their healing. The conclusion for most of these readmissions was that patients did not have the proper environment to promote healing and healthy living. Some had minimal access to healthy food choices while others did not own a scale to monitor daily weights. For others, the main issue was a lack of a strong support system to encourage and help them recover and maintain healthy habits.

This is not an isolated event but a situation that plays out in communities throughout the country.

They must be made a priority for each patient and the environments in which they recover taken into consideration.

In 1860, Florence Nightingale, recognized by many as the founder of modern nursing, defined nursing as: “the act of utilizing the environment of the patient to assist him (sic) in his recovery.”

Usually, health systems focus only on their facilities, over which they have control.

But what about the patient’s home environment where they will spend most of their recovery, not to mention most of their life?

Too often, healthcare providers and policymakers neglect the importance of helping the patient establish a healthy environment in which to live.

Hospital Readmissions Reduction Program

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that began in October 2012. The program reduces payments to hospitals with excess readmissions.
In other words, preventable readmissions are costing your hospital money, not simply because patients are returning for repeat treatment but also because you are being penalized by CMS (Centers for Medicare and Medicaid Services) in the form of decreased reimbursement.

Specifically, CMS is looking at excess readmission rates (ERR) for six common conditions and procedures:

• Acute Myocardial Infarction (AMI).
• Chronic Obstructive Pulmonary Disease (COPD).
• Heart Failure (HF).
• Pneumonia.
• Coronary Artery Bypass Graft (CABG) Surgery.
• Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA).

Historically, the reaction of most healthcare workers was to declare that they cannot control what patients do once they leave the facility – I know, because I was one of them.
While there is some truth to this claim, there is also much that can be done to influence a patient’s environment and lifestyle post-discharge to improve their health outlook and prevent unnecessary readmissions. I have listed five strategies below.

5 strategies to effectively address social determinants of health

1. Collect Data: Assess the needs of your community in the light of the social determinants of health.
   1. Develop a standardized screening tool focused on SDOH to be used throughout your health system for every patient.
   2. Train staff on SDOH.
   3. Communicate directly with patients, frontline staff, and community leaders on the role of SDOH and the need to gather accurate data.
   4. Identify the most common health issues and barriers to recovery/wellness (poverty, homelessness, education, mental health, transportation, access to food and healthcare).
2. Convince stakeholders.
   1. Discuss why you need to invest in SDOH. Explain why it is so important.
   2. Explain the financial benefits/ramifications (e.g. Improve the long-term health of the local population. Lower readmission rates.)
   3. Emphasize your hospital’s role in the community to serve its health needs.
   4. Recognize that they are not alone (Establish partnerships in the community).
3. Connect with Resources: Most effective solutions require teamwork.
   1. Community resources (government, private, religious, food banks, community centers, gyms, schools, service organizations, volunteer organizations).
   2. Payers (e.g. Insurance companies expanding coverage for mental health services).
   3. Providers (e.g. Standardize screening for SDOH and research effective methods for addressing specific SDOH. Establish a community-based care management program).
   4. Technology (e.g. Use technology to increase coordination outside of the hospital. Use telehealth to decrease Emergency Department visits).
4. Create an Action Plan: How will your hospital work toward health equity in your community?
   1. Establish guidelines for partnerships in community, payers, and technologies.
   2. Train employees on how to use a screening tool to develop a plan of care for patients and connect them with resources (maybe create an algorithm for specific SDOH).
   3. Educate patients on the importance of SDOH, specific to their situation.
   4. Provide patients with a Resource Directory (with a way to connect to resources).
5. Commit to your plan: Expect obstacles, financial and otherwise, and respond accordingly.
   1. Create tools to measure and evaluate the effectiveness of your Action Plan.
   2. Follow-up with patients, directly and through community partners.
   3. Evaluate the effectiveness of interventions and any changing needs within the community.
   4. Grow awareness and financial support for what your health system is doing to address SDOH and improve the health of the community.

Is it time for your hospital to consider your patients beyond the walls of your hospital?

Preventable readmissions do indeed cost your hospital money.

Promoting health is a worthy cause in which to invest, but too many hospitals have failed to explore how they can have a greater impact on their surrounding communities.

Social determinants of health play too large of a role in the health of your community to be minimized.

The “Band-Aid solutions” that we have grown comfortable with will continue to miss the big picture of population health and are probably costing your hospital more than you realize.

The relationship with your patients may start within the walls of your hospital, but it does not have to end there.

For a complimentary consultation, call our office today at 1-888-484-3332, Ext 500 or email us at info@viehealthcare.com.

[1] https://www.jhsph.edu/news/news-releases/2019/us-health-care-spending-highest-among-developed-countries.html
[2] https://www.visualcapitalist.com/5-ways-technology-healthcare-industry/
[3] https://www.healthaffairs.org/do/10.1377/hpb20180817.901935/full/