Experts agree the social
determinants of health are key patient wellness, but now efforts must center on
placing them into clinical practice.
By Sara Heath
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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