Social drivers of health: Evidence grows, but more connections are needed to help patients

Social drivers of health (SDOH) remain a key element if U.S. elected officials, policy makers, physicians, other clinicians and social service coordinators hope to improve the nation’s health care system for patients.

However, physicians and health care experts still are searching for the best ways to fit treatments into patient visits in the examination room and into patient experiences outside their doctor’s office.

A half dozen policy and clinical experts will be part of “Addressing Drivers of Health: What Works, What Doesn’t, and What’s Next,” a webinar panel discussion this month to address SDOH, also known as social determinants of health. They will discuss a decade’s worth of analysis and forecast the next best steps for physicians and other clinicians to help patients heal by addressing factors such as food security, housing stability, transportation access, utilities access, and interpersonal safety.

Two participants, Paul Harrington, Physicians Foundation board member and chair of the Drivers of Health Committee, and Dhruv Khullar, MD, MPP, director of the Physicians Foundation Center for the Study of Physician Practice and Leadership, spoke with Medical Economics about the current state of SDOH in health care.

A decade of analysis

This year marks the 10-year anniversary of the publication of “Poverty and the Myths of Health Care Reform,” Dr. Richard “Buz” Cooper’s book-length study that posited social factors had measurable influence over patient health and health care costs.

The book was “really an inflection point in our attitudes towards the impact of drivers of health,” Physicians Foundation President Gary Price, MD, MBA, told Medical Economics.

“He very conclusively, in a very simple, readable way, showed how actually that if you looked at patients' ZIP codes, that the explanation for these differences in cost actually broke down quite dramatically on the basis of poverty and some of the side effects of that, that, in fact, it was our poorest neighborhoods where the costs of health care were actually the highest,” Price said.

That phenomenon is not isolated to one time or place, Harrington said. In his own research, he compared the 83-year life expectancy in West Palm Beach, Florida, with the 67-year-old life expectancy of residents of neighboring Jupiter, Florida.

The contrast “hit me like a lightning bolt,” Harrigton said. He noted Cooper focused on health care usage and cost, not necessarily life expectancy, but the comparisons and analyses align.

“What is more important than life expectancy?” Harrington said. “I mean, if you've got a difference of about 16 years, 10 miles apart, that just validated to me the importance of dealing with drivers of health, to give everybody in this country the same possibility of leading a healthy life, and not have it determined by whether or not you have access to healthy food, whether or not you're living near a waste dump, or you don't have job opportunities.”

Learning from leaders

Harrington, Khullar and other advocates at The Physicians Foundation and elsewhere are not alone in recognizing SDOH and the need for new solutions that go beyond simply recognizing the problem.

“There has been a growing understanding of how important these drivers of health are,” Khullar said. “But I think there has been still a challenge in integrating and meeting patients’ social needs once they are in the health care system in some way.”

That’s a key reason for the panel discussion, said Khullar, who also is associate director of the Cornell Health Policy Center for Weill Cornell Medicine. Physicians, other clinicians, health care leaders and policy makers need to learn from people at the forefront of integrating social drivers of health into health care delivery, he said.

Khullar suggested some vital questions:

• What has been the most effective interventions in the past?
• What has been tried but hasn’t been particularly effective?
• If you could design a system, “a moonshot to move forward,” what would that look like?

SDOH — not a solo practice

Physicians, along with their office staff or the health systems that employ them, cannot do it alone, Khullar said. When systems or clinics have resources and partnerships with community organizations, those connections are valuable for physicians and support staff to match with patients in need.

“One of the challenges is that that is not always available,” Khullar said. “Often it is the case that there are communities where there are very few resources in that way. We have a system in which we're increasingly trying to get health systems to screen, for instance, for drivers of health to understand, at least at a very fundamental level, who in the community could benefit from support.

“But if there aren't actually those supports in the community, then that screening often doesn't go a very long way,” he said.

Out in the community

Those connections are not just theoretical or a benchtop experiment. The Physicians Foundation has awarded grants for pilot programs to medical schools and associations around the country. Harrington cited examples including Rush University Medical College. Cardiologist Danny Luger, MD, and medical students visit area food pantries to screen for blood pressure, blood sugar and cholesterol, part of the school’s Cardiometabolic Health Initiative.

“Food pantries serve people who lack access to healthy food they can afford, and such food insecurity itself contributes to chronic health conditions,” Luger said in a university article about the program.

In less than three years, the program has grown from a single visit to monthly clinics at four Chicago-area sites, with screenings for more than 650 people. It also has become a source of research, with findings published in Nature indicating 35% of food-insecure patients had prediabetic A1c, and 15% had a diabetic A1c level.

Where to start

Physicians can begin their efforts to address patient SDOH needs much the same way they treat other conditions: by building trust with patients to connect them with sources they need, Khullar said.

“The first principle is empathy, is trying to understand what it must be like for people who are struggling with those things and asking about them in a way that's respectful, but also helps people feel comfortable sharing that they are struggling with one of these drivers of health,” he said.

The issue is a challenge for not just for patients in need, but for physicians who want to help patients resolve needs that clearly are leading to adverse health conditions — but can’t. “I think both for the health of patients, but also for the sustainability of the workforce, this should be one of the prime issues that we're talking about as we're trying to reform the health care system,” Khullar said.