At Northwest
Permanente, a Portland, Ore.-based medical group of more than 1,400
physicians, a 15-year-old female patient, “Jennifer,” visited the Kaiser
Permanente Emergency Department 34 times in an 18-month period. Diagnosed with
Type 1 diabetes, the girl had developed major depression. Suicide attempts took
her to the ED twice, and her other visits were due to symptoms of uncontrolled
sugars.
Rather than simply
treating the diabetes and depression, the medical team began digging deeper
into Jennifer’s life. She had been missing school regularly. She lived with her
brother and her mother, who speaks only Spanish and works two jobs, keeping her
away from home most of the time. Their apartment had holes in the floor, and
mold and mildew in many corners, says Imelda Dacones, MD, president and CEO at
Northwest Permanente, P.C.
Northwest Permanente
connected Jennifer with a social worker who linked her and her family with a
Latina community health worker. Through that community health worker, the
family found better, more affordable housing and applied for financial
assistance. With increased financial stability, Jennifer’s mom no longer needed
to be away from home all the time.
After building trust
with authorities, Jennifer agreed to start seeing a mental health therapist and
to follow up more regularly with her doctor. She got control of her diabetes
and mental health, and graduated from high school. Now Jennifer is in college
and is thinking about a job in healthcare.
“Jennifer’s main
issues were not her depression and diabetes,” Dacones says. “Her medical
diagnoses—just as for all of us—do not define who she is. Screening for and
helping to address the things most important to our lives empower us,
ultimately, to own our total health. If we had only addressed her diabetes and
depression through a ‘medical lens,’ I don’t know where she’d be today.”
Jennifer’s story
exemplifies the importance of social determinants of health (SDOH), and how
doctors can help improve health outcomes by taking note of the non-medical
factors that may be affecting patients’ health.
Up to 90 percent of
health outcomes are a result of social, behavioral and economic factors,
according to recently-published data in JAMA Open Network. And
research shows that screening for the five leading SDOH—food security, housing
access, transportation issues, utility needs and interpersonal violence—can
greatly improve patient outcomes.
However, 33 percent
of physician practices do not screen for any SDOH and just 16 percent screen
for all five of the leading SDOH. Without the first four, patients may not be
able to purchase, store or take needed medications, or they may experience high
levels of stress, anxiety and fear, making them less likely to pay attention to
other health concerns.
Physician practices
are primarily focused on clinical care, but their clinical work will be more
successful if they start paying attention to patients’ needs beyond medicine.
“We should be
managing the entire patient, not just the medical portions of their care,” says
Nupur Mehta, MD, associate senior medical officer at CareMore Health, a
physician-led integrated care delivery system. “Considering not just the
medical needs, but also the entire spectrum of things that a patient may
benefit from has been invaluable in achieving the outcomes that we have
attained. Not to mention, it’s the right thing to do.”
Incorporating
Screening
Physician practices
can help patients attain their clinical care goals and take control of their
overall health by incorporating SDOH screening into their check-in procedures.
For instance, at CareMore, office staff screen for SDOH with Healthy Start, a
comprehensive assessment intended to gain more insight into the patient’s
medical, social and behavioral needs and to appropriately triage them into
disease management programs and services to support their care.
In addition, any time
a clinician is concerned about a patient’s needs, they are trained to ask about
access to core needs such as food, housing, and transportation.
Northwest Permanente
includes questions about SDOH with other data that is entered into each
patient’s electronic health record upon arrival, “much like you input vital
signs and other information about the patient,” Dacones says. “Having the form
for this information in the EHR in front of you prompts one to collect the data
in the first place.”
Atrius Health, a
group of 36 medical practices in Massachusetts, screens for nine SDOH every
time a child comes in for an annual pediatric checkup. The group uses a
questionnaire, which screens for a family’s access to permanent housing,
employment, ability to pay utilities, and access to food, transportation,
childcare, and mental health resources.
“This annual check-in
sees what’s happening outside of the clinic that can affect this child’s health
for the rest of their life,” says Stephen Parodi, MD, chairman of the Council
for Accountable Physician Practices (CAPP) which represents Atrius Health and
other large physician-led and ACO-focused medical groups.
Completing the Loop
Uncovering
non-clinical needs that affect patients’ health isn’t the final step. When a
practice finds that patients are hungry or lacking secure housing, they have a
responsibility to take the next step and assist in helping find a solution.
Various practices handle this responsibility in different ways.
Kaiser Permanente has
added a specific staff role to support this work, called patient navigators.
“Navigators are front-line public health workers and non-clinically licensed
staff who are extensions of the clinical care team,” Dacones says. “They are
there to help address the social and non-medical needs of our members by
building trusting relationships with patients, helping them to connect with
resources in their communities, and to activate individual patients’ care
plans.”
For some patients,
navigators provide resources and information that patients use to get their
needs met on their own. For those needing more help—such as those with a
language barrier or without a strong support system—a social worker or other
staff member may help them apply for housing or other community resources.
At CareMore, patients
who screen positive for an SDOH question are referred to an in-house team of
case management and community health workers. Working alongside clinicians, the
case management team helps connect patients with resources to address their
social and medical needs, Mehta says.
And at Arius, the
provider reviews a patient’s answers from the screening to understand any
potential needs. “Physicians then help connect patients with the resources to
help,” Parodi says. “They also have case managers and social workers on staff,
and a care facilitator will connect patients with other resources in the
community.”
Harnessing Technology
But even when
physician practices screen for SDOH, disconnect between their offices, other
care providers, and various community and social agencies can prevent patients
from getting the help they need to improve their health outcomes. But some
practices and regional groups are finding ways to use technology to simplify
the process and ensure that patients get help when needed.
Kaiser Permanente,
for example, is launching Thrive Local, a new social care network that will
connect member practices and patients to community-based social services
providers. Because the cloud-based network will be available to staff throughout
the system, as well as to community agencies, it will be easier to refer
patients to the help they need and follow up to make sure they received that
help.
“The goal is to
create a more holistic connection between the medical and social sectors to address
total health, moving beyond screening and one-way referrals to a
bi-directional, closed loop referral system with a robust network of social
care providers,” Dacones says. “Thrive Local will empower more staff who
encounter a patient with a social need to get that patient the information and
help they need.”
In addition to
closing the loop on meeting social needs that affect patient health outcomes,
such tech-based systems can generate data to help identify where community
resources are lacking and how SDOH affect the overall health of communities.
Social service agencies may also be able to use the data to demonstrate their
value to their communities and help secure funding.
The bottom line is
that when physician practices are aware of their patients’ needs beyond medical
care, they’re able to provide better care and patients are better able to
participate in achieving their own health goals.
“There’s a lot going
on in patients’ lives that affects their health, and knowing important things
like access to refrigeration changes what medicines I should prescribe, or
their access to housing will affect their diabetes care,” Parodi says. “As we
treat the whole patient, I believe it’s the physician’s role to help address
these wider needs.”
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