Social determinants play a major role in your health

Being healthy is at the top of many of our to-do lists. But did you know that social factors often have a greater influence on your health than the medical care you receive? Enter the social determinants of health.

What are social determinants of health?

Non-medical conditions that significantly affect health and quality of life are social determinants of health (SDOH). The US Department of Health and Human Services defines them as the conditions in the environments where people are born, live, work, play, worship and age that affect a wide range of health, functioning and quality of life outcomes and risks. They group them into five categories:

• Economic stability
• Education access and quality
• Healthcare access and quality
• Neighborhood and built environment
• Social and community context (relationships and interactions with family, friends, co-workers and community members)

Courtesy: Centers for Disease Control and Prevention

Interventions to address these issues include increasing income and housing stability; increasing educational opportunities and access to high-quality healthcare; creating neighborhoods and environments that promote health and safety; and increasing positive relationships at home, work and in the community.

“Each of these aspects affects the quality of life and health of a patient,” said Lynley Holman, MD, FACOG, a physician with Lawrence OB-GYN Specialists.

The Robert Wood Johnson Foundation estimates that social needs account for about 80% of health outcomes. This includes health behaviors like tobacco use, diet and exercise; social and economic factors such as education, employment, and family and social supports; and the physical environment, including air and water quality, housing and transit.

“Only 20% of medical intervention affects health outcomes,” said Sandra Dixon, director of behavioral health integration at LMH Health. “We can treat you for diabetes but if you don’t have reliable access to transportation, it impacts your ability to get to a medical appointment, pick up medication and get healthy food.”

Dr. Holman explained that due to the frequency of visits for expecting mothers, a lack of transportation can be a barrier to accessing care. This is especially true for those with high-risk pregnancies.

“The more complicated the pregnancy, the more attention it may require which results in more appointments,” she said. “We’re fortunate that the Maternal Fetal Medicine team from the University of Kansas Health System comes to Lawrence once each week to care for high-risk patients, especially those who have difficulty with transportation.”

Economic stability can also be a huge issue for those who are preparing to welcome an addition to the family. Patients who work and have weekly appointments with their OB-GYN may have to take time off, which is something that not all have.

“Sometimes our patients have to dive into their maternity time or miss hours which, in turn, affects the household income. Unfortunately, sometimes they have to quit or they get fired for missing too much time due to their pregnancy,” Dr. Holman said.

Identifying needs

Identifying the needs of patients is the first step. Beginning in 2024, the Centers for Medicare and Medicaid Services (CMS) will implement regulations that require screening patients.

“It’s about health equity and intentionally identifying the population of people who struggle to have equal access to healthcare,” Dixon said. “It’s about looking at and talking more about housing, food and access to childcare as factors into good or positive health outcomes, and not focusing solely on race and ethnicity.”

LMH Health has gotten a jump on the CMS requirement by implementing screenings for SDOH on the hospital’s inpatient floors. Patients age 18 and older are asked a series of questions upon admission using a tool called PRAPARE.

PRAPARE, which stands for Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences, is an evidence-based, nationally standardized risk assessment protocol designed to engage patients to assess and address SDOH. It was created by and for community health centers and has been adopted across the healthcare world.

“PRAPARE is consistent with what we do across the health system. We’re using evidence-based screening tools and decision making processes for conditions such as diabetes, heart disease and depression,” Dixon explained. “This tool is recommended by The Joint Commission – the group that certifies healthcare organizations in the United States - and is nationally known, so it allows us to compare our data to other health systems and see how we stack up.”

Addressing the problem

Once settled on an inpatient floor, a patient will be asked to answer a series of questions to assess food insecurity, housing instability, transportation needs, utility difficulties and personal safety. These include questions such as:

• What is your housing situation today?
• Are you worried about losing your housing?
• Has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
• Do you feel physically and emotionally safe where you currently live?

If answers to any of the questions identifies a need, it results in an automatic request for a consultation with a social worker. Dixon explained that while a social worker is assigned, the patient has the right to refuse help.

“If I’m admitted and have food insecurity, the social worker will come meet with me to get more information and ask if they can help,” she said. “It’s a collaborative process and the patient always has the right to say no.”

It’s not only hospital patients who are asked questions about SDOH. Those seen by the Population Health team and at Lawrence OB-GYN Specialists are also screened. 

“Our long-term goal is that no matter where a patient enters the LMH Health system or their primary location of treatment, information about their challenges flows with them and allows all of their healthcare providers to see it,” Dixon said. “While we don’t know a lot about our patients in this space yet, this will allow us to serve them better.”

The team anticipates that in the future, this data will be shared with partners in various settings to help influence community conversations. It can be challenging work, but Dixon said it’s important to take active steps to start addressing this need.

“We have lots of great connections with our community partners and this data will not only allow us to directly help our patients, it can help us influence some of the gaps in the community,” she explained. “I’m really glad that we’ve started the process of screening patients early and didn’t wait.”