If you’ve heard about the social determinants of health (SDOH), it may be thanks to campaigns launched by the American Academy of Family Physicians and the American Academy of Pediatrics. But if your workplace doesn’t actually screen for patients’ working and living conditions, you’re among the majority of healthcare providers, according to new research in the Journal of the American Medical Association.
For the study, the authors looked at whether physician practices and hospitals asked patients about food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence, using the 2017-2018 National Survey of Healthcare Organizations and Systems.
Analyzing responses from nearly 3,000 HCPs, researchers found just 24 percent of hospitals and 19 percent of physician practices screened for all five criteria; 33 percent of hospitals and 8 percent of physician practices screened for none. That means many providers are missing valuable opportunities to spot and address potential sources of serious health conditions among patients.
Here’s why you should care about SDOH screening — and the important role NPs, PAs and RNs play in incorporating it into everyday routines.
What are SDOH and why do they matter?
Social determinants of health (SDOH) are the conditions in the places people work, study, live and socialize, all of which have been found to affect a number of health outcomes.
Examples of SDOH, per the Centers for Disease Control and Prevention, include:
- Food and housing security
- Access to utilities and transport
- Interpersonal violence
- Economic stability
- Access to affordable healthcare
These factors create the conditions necessary for people to be healthy and thrive.
“I often tell fellow nurses that it’s not just the patient in the bed, but everything that they bring with them to the clinic or hospital — their environment and what’s going on around them,” Paul Kuehnert, DNP, tells Florence Health. Dr. Kuehnert is the associate vice president of programs for the Robert Wood Johnson Foundation (RWJF), a nonprofit focused on health equity and a leader in SDOH research and programming.
Dr. Kuehnert adds: Does the patient have a space to be physically active? What are their public transportation options? Where’s their nearest urgent care or pharmacy? What’s the quality of their school? All of these factors shape their health.
What does the research say?
To start, studies have found that economic insecurity can play a fundamental role in women’s risk of being diagnosed with HIV. In addition, social and economic factors may actually be more responsible for avoidable deaths from cardiovascular disease than an individual’s health behaviors.
Other research indicates that children between 1 and 5 who live in assisted housing have lower blood lead levels than kids who don’t receive housing assistance, and that kids whose families live paycheck-to-paycheck are significantly more likely to experience mental, behavioral and developmental disorders.
“Too often, when we talk about health, we point to the choices people make,” Dr. Kuehnert says. “We know personal responsibility certainly impacts people’s health. But the choices they make depend on the choices they have available to them.”
To take a practical example, housing affordability determines how much money a family can spend on other essentials they need to stay healthy. “When so much of a paycheck goes toward the rent or mortgage, it makes it hard to afford to go to the doctor, cover the utility bills, or maintain reliable transportation to go to work or school,” Dr. Kuehnert says.
Why are we hearing more about SDOH now?
The SDOH have become a hot topic after the Hospital Readmissions Reduction Program began levying financial penalties on healthcare facilities with excess patient readmissions. Instituted in 2012 by the Centers for Medicare and & Medicaid Services, the Medicare purchasing program aims to improve healthcare for Americans by linking payment to the quality of hospital care.
“As our healthcare payment incentives have shifted to being more value-based, rather than volume-based, I think we have seen an increased interest in assessing and addressing all the factors that impact a patient’s health,” says Dr. Kuehnert. “We are definitely seeing more healthcare delivery systems and many insurers address social needs of families through screening and referral.”
For changes to have a real impact, however, it’s important to address social conditions through policy and collaborative work across sectors. “Nurses can — and should — lead these efforts for health systems,” Dr. Kuehnert stresses.
Common misconceptions about the SDOH
Clinicians are sometimes reluctant to bring up SDOH with their patients, Dr. Kuehnert explains, because they’re afraid it will take too much time, especially in busy practices and hospitals. Asking about things like utility bills or transportation needs might also feel intrusive. And many health care providers may not have the proper referral mechanisms in place, so they aren’t sure what they’d actually do if a patient had a problem.
“What is feasible to address in a 15-minute clinical encounter? In inpatient settings, our systems are not often set up to help staff accurately capture SDOH as they are making their assessments,” Dr. Kuehnert laments. “I would argue that nurses spend more time with patients than physicians and are better-suited to assessing for the SDOH.”
A growing number of providers around the country are already successfully introducing SDOH screening tools into their practices. Facilities such as the Rush University Medical Center in Chicago and the ProMedica system in Toledo are beginning to require HCPs to incorporate screening for food security and other social needs in both inpatient and outpatient settings, Dr. Kuehnert notes.
How HCPs can address the SDOH in their patients and communities
Nurses and social workers are an important part of implementing SDOH, Dr. Kuehnert emphasizes. If your workplace doesn’t already have SDOH screening in place, he suggests first reviewing your community’s trends and challenges in RJWF’s annual County Health Rankings & Roadmap report.
Before conducting any screenings, put a plan in place for referral and follow-up. Start by asking for resources from your hospital’s social worker, or your local health department, or United Way. Once you’ve got a lay of the land and a plan, you can begin collecting and aggregating screening data for each of your patients.
Anxious about losing valuable time or intruding into a patient’s personal life? Think of information-gathering as simply listening while you perform necessary tasks.
“Think about the ‘small talk’ you make with the patient as you change a dressing, hang an IV solution, or take a blood pressure. Those are moments of connection,” Dr. Kuehnert says. “Getting the patient’s story doesn’t have to be time-consuming. We learn about family and friends. A book they’re reading. A favorite food. And, not coincidentally, those moments are also when patients will reveal to us important clues about their health — and about what might stand in the way of their healing.”
Finally, information can only have an impact if you act on it. So take an active interest in the role of your local government. “Don’t be afraid to speak up for policies that will remove obstacles to health for all,” Dr. Kuehnert adds.
Lipincott NursingCenter also highlights some concrete actions health professionals can take to raise awareness of SDOH:
- If you’re a teacher, incorporate SDOH curriculum into all clinical courses and ensure students routinely assess for SDOH in rotations.
- Request that your facility include SDOH in administrative policies.
- Stay current on proposed legislation and their potential effects on SDOH.
- Advocate for documentation tools that use SDOH measures, especially in EHRs and standard assessments.
- Establish a setting where staff can share ideas about addressing SDOH.
- Conduct research devoted to SDOH.
The CDC also offer resources to help practitioners tackle SDOH, too.