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.”
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.”
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.”