Assessing and improving social determinants of health begin with the patient-physician relationship.
As the U.S. health care system works to focus on the move to preventive, personalized care for patients, physicians need both time and support — particularly when it comes to engaging and empowering patients who are facing challenges related to social determinants of health (SDOH).
Providers now clearly recognize the significant role SDOH plays in health outcomes for people, especially for those living with chronic diseases like diabetes. Unfortunately, today’s current fee-for-service approaches to care simply don’t afford primary care physicians and other clinicians the time and resources to prioritize SDOH as a critical part of patient care and the overall patient experience.
Making this shift to a more holistic, collaborative, and proactive care environment hasn’t been easy, especially since the health care industry is heavily affected by organizational inertia and a reverence for tradition. Technical, financial, and cultural barriers have all made it difficult to implement more coordinated, value-based care — but there are near- and longer-term solutions that support the shift to a new perspective on collaborative, SDOH-focused patient care.
Despite feeling overworked and burned out, clinicians still have the drive to engage in challenging conversations with patients and follow up on issues outside of their clinic hours. However, the challenges and burdens they face can make it hard for them to strongly advocate for the right surround-sound support for patients.
To start, provider organizations and their health plan partners can support overburdened clinicians by integrating social workers into care teams. Social workers are the bridge between the clinical and nonclinical environments, and they can complete many of the SDOH-related tasks that physicians and nurses don’t have time or knowledge to address themselves. This includes ensuring patients are using all their health plan benefits, connecting individuals with community support groups, and providing education to assist with healthy decision-making.
Health systems must also do more to evolve care team structures that focus on expanding clinical capacity, giving back more time for physicians and nurses to complete their routine patient care duties, while also making space for discussing SDOH concerns with patients.
The direct value to patients of creating space for SDOH-focused activities cannot be overestimated, either. For example, one patient with diabetes in the U.S. Department of Veterans Affairs health system in Miami was chronically late to his appointments and refused to schedule his visits earlier in the day. When finally asked why, he said he always slept until 2 p.m. so he could skip breakfast and lunch. That’s because he couldn’t afford to pay for more than one meal a day. If we had never asked the question, we may have written him off as a “problem patient,” instead of someone who needed immediate help with his food insecurity.
Medical and nursing schools must take a larger role in preparing clinicians to engage in a collaborative care environment that prioritizes socioeconomically sensitive, empathetic care for people with diabetes and other chronic diseases. Often, new clinicians are expected to learn about SDOH at the residency level. In reality, that’s too late; by the time a clinician reaches residency, they are already deeply engaged in actively addressing SDOH concerns but haven’t had the formalized training to organize and guide their approaches.
Teaching students to ask the right questions of the right stakeholders and work with patients in a stigma-free and culturally appropriate way will increase comfort with having challenging discussions about sensitive topics and finding solutions for issues within the care continuum.
At The University of Texas Rio Grande Valley, for example, students participate during dedicated modules to better understand the factors that influence SDOH and how to discuss these issues with patients in real-world settings. These modules are paired with interprofessional education options to familiarize students with working alongside social workers, behavioral health care providers, podiatrists, nephrologists, and other specialties to deliver holistic care to people with diabetes.
By introducing these relationships early in the educational process and creating structured guidance around how to leverage these interactions in the real world of patient care, providers can start their careers with the competencies to shape a more coordinated future for whole- person chronic care management.
Building up healthy and resilient communities requires providers to reach beyond the walls of the clinic and truly connect with organizations that influence daily habits and help prioritize healthy choices. These may include schools, faith-based groups, nonprofits, or veterans’ associations that have close ties to residents and deeply understand the environmental and cultural issues that may contribute to patient decision-making.
For example, the American Diabetes Association (ADA) recently partnered with the Elevance Health Foundation to enhance its What Can I Eat? program: an in-person and virtual initiative to bring nutrition education, free healthy foods, and other resources directly to underserved communities in Indiana, New York, Ohio, and Virginia. The ADA is currently looking for more community-based partners in these regions to facilitate the in-person components of the program.
A renewed focus on empowering clinicians with social worker support so they have more time to focus on compassionate care; enabling stronger care collaboration as part of the medical education process; and powering a new, proactive approach to tapping into community assets will go a long way toward addressing the SDOH challenges being faced by many people today. Only then will people living with chronic diseases, like diabetes, have the chance to access the type of value-driven, equitable care that we all deserve in the 21st century.
Gary Rothenberg, DPM, CDCES, CWS, is director of medical affairs at Podimetrics; adjunct clinical associate professor of internal medicine at the University of Michigan; and a board-certified podiatrist with more than 20 years of experience that includes academia, clinical practice, and research.