Wednesday, September 25, 2019

Putting Social Determinants of Health to Work in Clinical Practice


Experts agree the social determinants of health are key patient wellness, but now efforts must center on placing them into clinical practice.
September 16, 2019 - For Thomas McGinn, MD, MPH, of Northwell Health, the medical industry has moved past its laser focus on the social determinants of health. Now, hospital and health system leaders are looking at strategies to integrate social determinants work realistically into clinical practice.
“We've moved out of this phase of social determinants,” McGinn, who is the director of the Institute for Health Innovations and Outcomes Research at the Feinstein Institutes and senior vice president of physician network operations at Northwell Health, told PatientEngagementHIT.com. “Social determinants are clearly important. They impact on everybody's health care. But now that we have a few well validated tools for collecting data, some of the work that's going on is how do we integrate this in the most efficient way?”
The healthcare industry is in clear agreement that the social determinants of health – or the social factors that influence an individual’s ability to be healthy – are essential to delivering holistic, patient-centered care, according to McGinn. It’s time for the industry to take the next step and look at its action plan for integrating the social determinants of health into the exam room.
This will go beyond getting the right kind of technology to gather social determinants data, although that is important, McGinn explained. Instead, it will center on making that data usable for the patient and provider.
“How does one integrate this into a health system in a meaningful way so that both the patients and the physicians can easily integrate some of this information and fully utilize it, as opposed to it being a burden and irritating and just another checkbox of many,” McGinn, who also recently co-authored a paper on integrating social determinants into healthcare practice, noted.
There’s still a lot to figure out, McGinn asserted, and the healthcare industry is in a constant state of experimentation and evolution. What undergirds all of these efforts is an ability to be agile and a willingness to pilot and iterate.
These efforts are going to look different for every facility, depending on specific population health needs, provider staffing and resources, and connections into the community.
“Depending on what you call social determinants, if you're trying to cover everything, there is a lot there,” McGinn explained. “You could be looking at transportation, housing security, food security, or safety at home.”
The industry is on the cusp of figuring out how to make the social determinants of health a part of medical practice, and as with any industry-wide shift, challenges abound.
For one, organizations are faced with time constraints, an issue that pervades nearly every change management effort. When it comes to the social determinants of health, industry leaders point out that providers don’t always have the time to integrate these conversations into already too-short primary care visits.
Some organizations are having luck with artificial intelligence, McGinn explained. AI tools help detect which patients might be struggling with one or more social determinants of health, and based on certain factors included in the search algorithm, providers can narrow their social determinants conversations.
“There was one publication that we cited in our article about using artificial intelligence to try to look for who might be a better targeted population,” McGinn explained. “Instead of screening a thousand patients, maybe you would screen one hundred.”
AI algorithms could look at Medicaid populations or patients with symptoms that are consistent with experiencing homeless, although McGinn added that more research is needed to determine what factors AI could consider.
Other organizations are looking for strategies to remove the clinician from the equation altogether, at least as it relates to data collection. Most industry leaders agree that someone else, like an administrative worker or the patient herself, should be entering their social determinants data instead of the provider.
Using waiting room patient intake kiosks or iPads or patient registration checklists are the leading approaches for this. But from there, organizations are struggling to find the personnel to address any emerging patient needs.
In more advanced practices, like some of those at Northwell that are patient-centered medical homes (PCMHs), this is easier. PCMHs employ a lot of different medical professionals beyond doctors and nurses, including dietitians, nutrition experts, case managers, and patient navigators.
Some clinics might even have dedicated staffers who address specific social determinants of health, like medical legal partnerships that help patients navigate housing issues or domestic violence incidents.
“But then again we have some primary care sites that have just a doctor and a nurse,” McGinn acknowledged. “The roles vary by site and what's available. Where at one site where you don't have all those community folks available, the patient may just be filling it out on their own and the doctor receives all the information and then deals with it directly.”
It’s become clear that having community partners is crucial for any clinic, but especially those with fewer staffers dedicated to addressing social determinants of health. By building partnerships with community-based organizations (CBOs), like churches or homeless shelters or public transportation firms, medical providers can help close the gap in addressing social determinants of health.
“A lot of health systems are building those links and relationships, and that’s important,” McGinn stated. “Not every health system's going to have the ability to have a pharmacist, a dietician, a psychologist, a lawyer readily available in their clinic. That's unrealistic. But many of the community organizations will have some of those different resources available. The question is how connected are they to the health system?”
And once those community partnerships have been established, questions still remain.
“The point that we're not clear yet is, did the patient actually go to the CBO?” McGinn posited. “Did they actually benefit from the process? That part hasn't really been looked at very carefully.”
The medical industry is becoming acutely aware of the challenges patients face in accessing community-based support. They might not have an actual ride to get to a homeless shelter, or have to go to work instead of to the healthy eating workshop to which their nurse referred them.
Stigma especially can limit patients from accessing community-based services, McGinn pointed out, noting that stigma will serve as a significant barrier when discussing and addressing social determinants of health. Providers must ensure they address these social factors in a way that is not disempowering for patients.
Much like how primary care providers have chipped away at mental health stigma (although that remains an issue as well), they must also regularize discussions around social needs.
“Patients must know that everyone is being screened and the physician or the practice isn't targeting them,” McGinn asserted. “Let patients know this is a normal thing that everyone is being screened for.”
Clinicians can tell their patients that they appreciate that they may not struggle with social determinants, but that these screenings are run of the mill. And when a patient might struggle with social determinants, clinicians should let their patients know that when the practice can identify it, they can rectify it.
But practices need to strike a careful balance between making social determinants of health screenings standard – a box-checking activity, McGinn said – and emphasizing meaningful discussions around social needs. Providers need to be engaged in these conversations, and the first step toward that goal is reframing how the industry establishes the social determinants evidence base.
Instead of making social determinants screenings mandatory, government policymakers should work with industry leaders to experiment. Only then can the industry see innovation, not passive mandates.
“What the federal government should do is fund different pilot projects to see what is the most efficient way to do this screening,” McGinn concluded. “Pilots should entail complex forms of usability studies where we study the culture of a visit with a patient, and patient or provider burden.”

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