April 2020

SDoH: Behind the Buzz Is Real Potential
By Elizabeth S. Goar
For The Record
Vol. 32 No. 3 P. 14

As the call to make better use of social determinants of health intensifies, health care organizations are trying to figure out how best to integrate them into practice.

Social determinants of health (SDoH) are health care’s current obsession, with supporters touting the impact these socioeconomic factors have on an estimated 80% of a person’s overall health. Factors such as a lack of access to reliable transportation or nutritious food and/or the limited availability of affordable housing have been linked to higher utilization of the most expensive health care services, including emergency department visits and hospital admissions.

Therefore, it is believed that arming physicians and other care providers with a combination of SDoH and clinical data could be transformative when it comes to population health.

“As health care policymakers increase their efforts to move toward accountable care or value-based payment models, there is heightened emphasis on environmental and cultural factors that lead to increased utilization of medical services. So small-step interventions in transportation, nutrition, housing, and public safety could have a significant bearing on major medical costs,” says Larry Burnett, a principal with KPMG LLP.

Unmet Needs and Sociodemographic Stress
A convergence of factors is likely the catalyst for the attention being paid to the impact of social determinants on an individual’s total health, says Anand Shah, MD, vice president of social health at Kaiser Permanente. Factors include “increased awareness of the impact of unmet social needs, availability of tools to help address social needs, and aligned accountability and incentives in risk-bearing programs like accountable care organizations,” Shah says.

In fact, according to the June 2019 “Social Needs in America Survey” from Kaiser, 68% of Americans surveyed reported experiencing at least one unmet social need in the past year. More than one-quarter reported that an unmet social need was a barrier to health, with 21% prioritizing paying for food or rent over seeing a doctor or purchasing a medication.

People living in the United States reporting unmet social needs were twice as likely as other respondents to rate their health as fair or poor, and one-third of respondents reported experiencing stress related to social needs. In addition, 39% frequently or occasionally experience stress over accessing food or balanced meals and 35% experience stress over housing.

According to Burnett, several social factors can be used to determine the overall level of sociodemographic stress experienced by individuals. These include the following:

• Home stability: Home composition and likelihood of eviction or foreclosure due to affordability of housing;

• Financial stability: Likelihood someone will not be able to afford medical expenses or other costs necessary to maintain their health;

• Food access: Availability and affordability of healthy food options;

• Transportation: Availability of private or public transportation options to travel to providers of needed health services and products; and

• Health literacy: Likelihood someone will not be able to comprehend topics or discussions related to their medical condition/risks and/or care plan.

While the use of SDoH is evolving, Burnett notes that “our initial impressions are that these scores greatly enhance the ability of the caregivers to address social and medical needs to improve the care of both individuals and populations.”

Added credence to the potential impact of SDoH came when the Centers for Medicare & Medicaid Services (CMS) recently called them out in its modifications to Medicare Advantage plans for 2020. In its final policy update, the agency gave chronically ill plan members access to benefits that, while not directly health related, can reasonably be expected to improve or maintain the member’s health or overall function.

Among the examples cited by CMS are meal deliveries, transportation for nonmedical needs such as grocery shopping, and home environment services (eg, air cleaners and carpet shampooing to reduce irritants that could trigger asthma attacks).

“Larger health systems and some payer organizations are increasingly using SDoH data for their programs, which, in turn, has led to substantial investments to address nutritional, housing, and transportation needs in the communities they serve,” Burnett says. “However, a JAMA study published in September [2019] found nearly one-quarter of hospitals and 16% of physician practices screened patients for all five social determinants of health prioritized by the CMS: food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. There is a long way to go in collecting these data and taking them into account for treatment programs.”

Screening Prevalence
That study, “Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals,” was conducted by The Dartmouth Institute for Health Policy and Clinical Practice to determine the extent to which screening for CMS’ five priority social needs was taking place in hospitals and physician practices. Researchers conducted a cross-sectional study using national survey data, collecting responses from 2,190 physician practices and 739 hospitals between June 2017 and August 2018.

Researchers found that most US physician practices and hospitals report screening patients for at least one of the five social needs. Most common was screening for interpersonal violence, while utility needs were the least common.

Hospitals and practices that serve more disadvantaged patients reported higher screening rates, with nearly one-third of federally qualified health centers screening for all five social needs. Higher rates were also reported by practices with exposure to delivery and payment reform (eg, primary care improvement models, bundled payments, commercial accountable care organization contracts) and academic medical centers.

Resource limitations, both financial and time, were identified as a significant barrier to increasing screening rates by physicians and hospitals “when they have no real capacity or ability to address those needs, especially given the lack of robust studies behind screening,” the researchers wrote.

They continued, “Physicians and hospitals likely have limited resources to help patients truly solve needs such as economic insecurity. Practices and hospitals in our study reported major barriers to innovation in clinical care, including a lack of resources, incentives, and time. Screening for social needs represents a major care-delivery innovation, and physicians and hospitals may need additional processes to link patients with local resources to address identified needs.”

The National Academies of Science, Engineering, and Medicine has also taken a closer look at SDoH, issuing a consensus committee report in April 2019 reviewing the evidence on how social care is being integrated into health care. “Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health” identified and assessed current and emerging approaches to SDoH and recommended ways to expand and optimize social care in the health care setting.

It identified five complementary activities that can facilitate the integration of social care into health care: awareness, adjustment, assistance, alignment, and advocacy. Of those five, adjustment and assistance focus on improving delivery of care to individual patients based on their social needs, while alignment and advocacy relate to roles that the health care sector can play in influencing and investing in social care resources at the community level. All five activities are informed by efforts that increase awareness of individual or community-level social needs in a health care system’s geographic region or for its served population.

“Perhaps the most compelling aspect of this process for me was the intense interest in this topic from a variety of different sectors and the number of different ways local efforts are experimenting with models for addressing the social needs of patients in the context of health care delivery,” says committee chair Kirsten Bibbins-Domingo, PhD, MD, MAS. “Our committee report sought to provide a framework for thinking about this work and the essential elements required to do it well,” including a well-trained workforce, digital infrastructure, and financing models that support this work.

Bibbins-Domingo, who is the Lee Goldman, MD, Endowed Chair in Medicine and a professor of medicine, epidemiology, and biostatistics at the University of California, San Francisco, notes that while there is no one-size-fits-all way to integrate SDoH into practice, the committee did identify five goals of integrating the components into health care and recommended the following:

• design health care delivery to integrate social care into health care, guided by the five complementary activities;

• build a workforce to integrate social care into health care delivery;

• develop a digital infrastructure that is interoperable between health care and social care organizations;

• finance the integration of health care and social care; and

• fund, conduct, and translate research and evaluation on the effectiveness and implementation of social care practices in health care settings.

“The committee recommended that health systems that are interested in doing this work use validated screening tools and engage members of the entire health care team, including frontline staff, as well as community members and patients to determine best approaches in their setting for these tasks,” Bibbins-Domingo says.

Additional recommendations include the following:

• Health systems should establish and financially support strong linkages with social sector partners.

• Payers such as Medicaid and Medicare must continue with alternative funding models to allow for more demonstration projects on integrating social care into health care delivery.

• States and Medicaid need to communicate to health systems what is covered as “health care” within current regulations (which is most likely more than is currently pursued).

• States should leverage the community benefits requirement for nonprofit hospitals to continue urging health system investment in community needs.

“This is important work—but work that requires thoughtful plans for implementation. Health care professionals often feel ill-equipped to address the social needs of their patients, so models that integrated this type of care more effectively have the potential to address this concern,” Bibbins-Domingo says. “The committee identified the need for commitment on the part of health system leaders to organization and resources necessary for successful implementation, engagement of clinician and staff champions, and thoughtful planning with attention to workflows that includes clear goals, protocols, and implementation plans.”

Closing Gaps to Expand Adoption
According to Shah, patients want and expect the health care system to address their social needs, noting that 80% of survey respondents said they would find it helpful for their medical provider to deliver information, recommend specific resources, and help them access social services.

However, on the provider side, “there is both a lot of excitement and some trepidation. The interest in addressing root causes for patients’ health aligns with why most clinicians entered the health care field. However, many clinicians feel overburdened in their clinical environments and are wary of additional programs,” he says. “So, the key is to integrate social health into care by building systems that are both effective and efficient for clinicians and staff.”

As is often the case, HIT is the underlying framework needed to successfully integrate SDoH into the care continuum. According to Burnett, technology has an important role in coordination of care among doctors, hospitals, payers, social work organizations, and patients. “There is a reason why it is called a ‘social safety net’: to allow for interventions that can address gaps in care,” he says.

Burnett says HIT systems have improved over the past decade with the help of HITRUST funds to establish EHRs, as well as earlier investments in ePrescribing and other technologies aimed at reducing errors and adverse events.

“[However], we need to optimize these networks much better and integrate them across the continuum of care,” he adds, noting that the organizations that are not incorporating SDoH data into their systems are creating gaps in addressing preventive and subacute care. “We’re doing a much better job at collecting the data when a patient is at the doctor, pharmacy, or hospital, but the issue is how that patient is living when they are not receiving care from a clinician.”

While he agrees that enabling access to patient information “no matter where patients are in the system” is a barrier to widening the scope of SDoH, Alonzo Plough, vice president of research, evaluation, and learning and chief science officer for the Robert Wood Johnson Foundation, believes there is a larger hurdle to clear.

“The biggest barrier is getting interoperable data systems between social services, public health, and [clinical] data systems like Epic,” he says. “In the context of HIPAA compliance, which is critical, those are the tech issues. [But] while there are lots of technology challenges, a lot of work is being done on integration and being able to monitor what information is going where.”

For SDoH to have a true impact on health outcomes, Plough points to the importance of bringing patient-generated information into the equation. Patients, he says, understand their social conditions, and those with chronic conditions are cognizant of how these factors affect their disease states.

“In the field we call it lived experience, and it’s absolutely critical on the data front,” Plough says. “The lived experience, a provider-patient dialogue that values the information patients provide, and sharing data between patients and providers in formal ways, those are a critical part of bringing social experience to the clinical setting.”

— Elizabeth S. Goar is a freelance writer based in Wisconsin.