What are social determinants of health?

Only 20% of health outcomes are influenced by clinical care. 

That’s right. Only 20%.

It turns out that the other 80% of health outcomes are influenced by social determinants of health (SDOH). 

What are social determinants of health (SDOH)?

SDOH are “the conditions under which people are born, grow, live, work, and age,” according to the American Academy of Family Physicians (AAFP). These conditions can include risk factors such as food scarcity, secondhand smoke inhalation and unsafe neighborhood conditions. 

Unfortunately, no amount of clinical care can take away these risk factors, and yet these risk factors are incredibly common. In fact, 60% of consumers reported that they were adversely affected by at least one SDOH in a Leavitt Partners 2019 survey. 

And the COVID-19 pandemic didn’t help: it actually exacerbated the connection between inequality and health outcomes. Although only 20% of health outcomes are influenced by clinical care, physicians can still play a huge role in SDOH for their patients. Organizations such as the AAFP, CDC and World Health Organization have even made great strides to encourage or assist physicians in their SDOH efforts. The American Heart Association has a SDOH assessment tool to help with routine care for patients with heart failure.

The 5 categories of SDOH

SDOH can be difficult to wrap your head around, but the Department of Health and Human Services breaks SDOH into 5 categories.

Economic stability refers to factors such as income, cost of living, food security and housing stability, etc. In the United States, one in ten people live in poverty, often having to choose between primary needs like rent or food and medication. They literally can’t afford to maintain their health.

Plus, research shows that food insecurity is one of the most critical health and nutrition issues, especially in children. Food insecurity can lead to many negative health outcomes such as anemia, asthma, aggression, anxiety and poorer oral health. 

Furthermore, “food insecurity is a more powerful predictor of pain and prescription opioids use than income,” according to population health research.

Education access and quality refers to factors such as literacy, early childhood education, and educational attainment.

We’ve heard it before: it’s harder to get a good job without a high school diploma, at least. But it’s true. Without a high school diploma it’s substantially more difficult to earn a well-paying salary and that makes it harder to afford food, transportation, housing, and healthcare.

In fact, research shows that “high school dropouts were at increased odds of reporting a serious chronic health condition (e.g., asthma, diabetes, heart disease, high blood pressure) even after accounting for the influence of age, income, gender, marital status and any alcohol or drug addiction.” 

Health care access and quality refers to factors such as access to health care, health insurance coverage, health literacy and primary care access.

According to the Commonwealth Fund’s 2020 Biennial Health Insurance Survey, 35% of all adults are “at least one cost-related problem getting needed health care in the past year including not filling a prescription; skipping a recommended test, treatment or follow-up visit; not going to a doctor when sick; or not getting needed specialist care.”

Other research shows that “low health literacy is associated with poorer health outcomes and poorer use of health care services.”s

Neighborhood and built environment refers to factors such as access to transportation, air and water quality, housing quality and neighborhood safety, along with other factors like secondhand smoke exposure and noise pollution.

Have you ever thought that where you live could be what is making you sick?

Though there are multiple reasons a neighborhood could affect health, something to consider is indoor air quality. Indoor air pollution can negatively affect health for everyone, but especially those with respiratory or cardiac concerns. 

Another issue, lack of transportation, can also negatively affect health, as it can make people late or miss doctor appointments, delaying or preventing care.

Social and community context refers to factors such as civic participation, having a supportive community, incarceration, workplace conditions and discrimination.

As it turns out, mental health (e.g., psychological stressors such as loneliness or racism) can have a huge effect on physical health. 

USC and UCLA research found that racist experiences increase inflammation and raise the likelihood of chronic illness in Black patients. As it turns out, Black people are more likely to die from cancer and heart disease than white people, and Black neighborhoods generally have health care provider shortages.

What should physician practices do about SDOH?

The two most important things a physician practice can do when it comes to SDOH is to 1) screen patients for risk factors and 2) offer resources such as contacts or locations that can help them.

Remember how 60% of consumers reported that they were adversely affected by at least one SDOH in a Leavitt Partners 2019 survey? It turns out that these patients weren’t often screened for SDOH needs. For instance, only 9% of survey respondents who struggled with food insecurity said someone in their doctor’s office asked them about food access.

How do you screen for SDOH risk factors?

• You could embed SDOH questions in the practice EMR. This method can “assist in risk assessment and predicting healthcare utilization and health outcomes,” according to research.
  
• You could use SDOH screening forms in patient pre-registration or registration. Be sure to look into AAFP’s SDOH toolkit for a baseline template for your own practice. The three main points of their toolkit are to assign specific tasks to specific roles, use one of the toolkit’s screening forms and know your execution plan.

How do you actually help patients?

• Help patients with Medicaid enrollment.
  
• Use AAFP’s Neighborhood Navigator, a resource that provides access to up-to-date local listings of more than 40,000 community-based resources throughout the United States.
  
• Have patients use 2-1-1, a free and confidential 24-hour service that helps Americans find local resources. Call, text or visit 211.org.
  
• Refer patients to local community resources such as the local health department, food banks and senior citizen programs.
  
• Hire a patient navigator who can help patients coordinate care, understand insurance coverage and find community resources that can help with SDOH needs.

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Rivet is a modern revenue cycle product suite that integrates with your EHR to allow you to see the big picture of what’s going on in your practice with payer contracts, fee schedules, denials and underpayments. You can also check eligibility and provide accurate up-front patient cost estimates before services are rendered. The Rivet team will help you aggregate your fee schedules and input your claims data to enable you to increase revenue and decrease A/R days. 

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