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A team approach to addressing social determinants of health


When it comes to patients struggling with social issues, a little effort on the part of the practice can go a long way.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

Much attention these days in the world of healthcare and population health management falls on the idea of social determinants of health.

Comprehensive Primary Care Plus (CPC+), the new model of delivery of primary care supported by the CMS understands that good physical and mental health are dependent on a fairly high degree to a patient’s social situation.  The idea of providing more complete care must also address a patient’s social setting. Many more people in the United States over the next several years will be screened for social needs and referred to helpful community services.

Practices involved in CPC+ have chronic care managers (CCMs), clinical staff who reach out to our more seriously ill patients and those with chronic illnesses to improve care, cut down on hospitalizations, and decrease emergency room visits. This will not be successful unless certain social barriers can be overcome. For instance, if the congestive heart failure patient is not taking his prescriptions because he cannot afford it, then this patient will definitely bounce back into the hospital. If the diabetic patient has a food shortage and is still giving herself insulin, again there will be an unexpected ED visit for hypoglycemia. Or if the diabetic patient is using the food pantry because funds are tight, and getting mostly high-carbohydrate foods, then his hemoglobin A1C is not likely to improve. If the smoking patient with peripheral vascular disease doesn’t have transportation to the wound doctor for follow up on an arterial ulcer, then again, he may have an unexpected admission and possibly a very poor outcome.

Most clinicians are able to buy the groceries they want and need, and drive or take public transportation easily to work, appointments, and the grocery store. The majority of primary care providers live in safe neighborhoods.  Many of our patients are not so fortunate.

By exploring social determinants of health, practices can make some significant improvements in patient care. Using EHRs, practices can target select populations of our patients by several different means including zip code, chronic conditions, high risk patients, smoking status, or uncontrolled diabetes. The CCM nurse can then further assess need by an actual face-to-face visit, over the phone, or by written survey to determine what social aspects in the patient’s life are causing the physical and mental health not to thrive.

The CPC+ team, with the CCMs, gathers information on community services available to people and builds a database of resources. Community relationships are built. In our office, we now have lists and phone numbers available that were previously not at our fingertips, available to aid our patients, including:
• the hotline for the homeless (It is hard to store insulin living in your car.);

• all of the local food pantries (Several do not require a minimal income, clients may shop for food if they have lost their job and just need temporary help.);

• churches that provide hot meals or shelter (One local church runs a “code blue” program to get people off of the streets on nights when the temperature is below 36 degrees.);

• public transportation numbers;

• Agency for the Aging numbers; and

• all kinds of in-house help agencies numbers (such as Senior Helpers and Home Instead).

Our nurses will set up the appointment, or make the initial call to get a homeless person in touch with the right community service provider to start the ball rolling.

Unfortunately, there is currently not an efficient or reliable way to define and measure success. There is no way to electronically capture the fact that improving social needs improves the quality of care delivered.

Of course, if we find the homeless patient a place to live, that is a success. But can we measure if it decreased cost and hospital utilization, improved the patient’s blood pressure and lowered her A1c? Even if we can’t measure the improved quality in the patient’s health, I think we can all agree, these types of little victories are beneficial for everyone involved, and reflect an improvement in the providing of care.

Lori Rousche, MD, is a family medicine physician practicing in Souderton, Pa., where she operates under the Comprehensive Primary Care Plus model.

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