A new report from national nonprofit The Root Cause Coalition finds important gaps when it comes to addressing the economic and social conditions that cause healthcare disparities in the United States — and notes that nurse practitioners in particular are ideally suited to take up the challenge.
“Our report found that nurse practitioners were more likely to have received training on how to address health equity and social determinants,” says Barbara Petee, executive director of the coalition based in Washington, D.C., which recently issued “The Status of Health Equity Report” on social determinants of health. “We also learned that nurse practitioners were most likely to ask patients if social or economic hardships exist.”
Sophia Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners tells Florence Health that the report is “a call to action for people who can make a difference in the lives and healthcare of the individuals who are really impacted by social determinants of health.”
Social determinants of health include food security, employment, transportation, housing, education, and other social conditions that influence an individual’s well being. Prioritizing these underlying issues, the coalition argues, creates a way to control health-care costs and produce a healthier society.
Currently, one in 10 seniors in the United States lives below the federal poverty level, the report notes. In addition, 40 percent of American families struggled in the last 12 months to meet basic needs of food, healthcare, housing or utilities, it says. “When a person’s ZIP code — or ZNA — is more of an indicator to overall health and well-being than their DNA, we know the current model of health care is badly broken,” the report explains.
According to Thomas, awareness that social and economic factors can affect health has increased in recent years. “We know that the real issue, addressing these social determinants of health, will have a huge impact on overall health and well being. This report puts words to what I’ve seen as a trend,” she adds.
The survey of 200 clinicians (primary care physicians, nurse practitioners and physician assistants) found that, at 53 percent, NPs are most likely to routinely address health equity with patients compared to 40 percent for PCPs and 35 percent for PAs.
Thomas is not surprised. NPs, according to her, are rooted in patient care and strong communication skills, beginning in nursing school. “Nurse practitioners are very skilled and adept at talking about the elephant in the room,” she says, “and having those uncomfortable conversations in a caring and compassionate manner, to really tease out the underlying conditions, to provide care to patients.”
By 2025, the report urges the adoption of eight policy recommendations, including Medicare/Medicaid reimbursement for community-based services that address health-related socioeconomic issues; an integrated platform that connects patients, payers, providers and community services groups; improved provider training on the impact of social determinants of health; metrics for measuring health outcomes related to racial disparities and socioeconomic impact on health.
“There needs to be increased efforts to educating and training health providers on health inequality and the role we play in addressing these health issues,” Thomas says. “How do we effectively integrate this new role into our practice? We can do this.”
Barriers, however, exist. The survey found that:
Sixty-nine percent of NPs say they do not have enough time during an office visit to address socioeconomic factors that impact health outcomes.
Typically, practices allot 15 minutes for sick visits and 30 minutes for well visits, such as physicals. The shortness of sick visits is “a barrier across healthcare in general,” Thomas says. Still, in her own practice in a medically-underserved area of New Orleans, she says she takes the time needed to understand a patient’s concerns and to explain care and solutions. “If that means missing lunch to spend extra time with my patients, I’ll do that.”
As important, Thomas adds, is creating a safe environment where patients are comfortable discussing these issues. “Many people have pride,” she says. “It’s a hard thing to admit insecurities about buying food, or that you do not feel safe in your house. Asking questions is one thing, but also explaining why it’s important to have this understanding.”
Sixty-nine percent of NPs also say limited resources affect the ability to provide help, especially for administrative follow-up of care plans for patients.
In addition, many clinicians favor national health insurance payment reform to cover nonclinical services critical to well being.
“We prescribe medication when somebody’s sick,” Thomas says. “Wouldn’t it be great if we could prescribe good nutrition, be proactive in preventing health conditions?”
At her practice, which is a Federally Qualified Health Center that receives federal funds, every patient takes a survey of social determinants of health at the beginning of each office visit. For example, it asks: Are you worried about food? About transportation? Do you feel safe in your home? What stressors are you experiencing?
“Then we try to match them up with a caseworker who helps them get the services they need,” she says. “It really makes a difference.”
Fifty-eight percent of NPs, however, say community resources are not integrated into their practices, hindering effective help.
Thomas allows, and the report confirms, that many nonprofits that provide community-based services lack the budget to market themselves or communicate what they can offer to health-care providers.
That said, “nurse practitioners are really good at finding out what social support systems are available in their communities and plugging in patients that have needs,” she says. In her own practice, the office maintains a master data base that includes services that organizations provide, such as local churches that might have baby formula and diapers; food banks, and more. An on-site social worker helps patients make get help.
In addition, clinical pathways in the electronic health record can help motivate clinicians to ask or continue asking patients about social determinants of health, the survey found.
Even though only 29 percent of NPs, and even fewer PCPs (24 percent) and PAs (18 percent) thought primary care providers should be responsible for health equity in their community, putting the onus on public health departments, policymakers and community organizations, many still make the effort.
For NPs, Thomas says, these conversations are about looking at the patient holistically.
“Health isn’t just an absence of illness,” she says. “It’s really a mental, physical and social well being that needs to be present wherever we live, work and play.”