Addressing the Social Determinants of Health

Allscripts Medical Director Dr. Geoff Caplea discusses the critical role of social circumstances for patients’ health and well-being. From a high-level overview of the social determinants of health, to looking at how health IT can play a role in helping clinicians identify the social factors for more informed care, Dr. Caplea provides a full picture of how the industry is adapting to drive better care across communities.

GC: Before diving into social determinants of health, let’s start by looking at the bigger picture.

As Dr. Steven Schroeder illustrated in the New England Journal of Medicine (NEJM) article titled, “We Can Do Better – Improving the Health of the American People,” there are factors in five domains which contribute to an individual’s overall health – genetics, individual behaviors, environmental exposures, medical care and social circumstances. And while medical care has historically received the greatest share of resources and attention, social and economic factors are far stronger determinants of health outcomes.

The World Health Organization (WHO) defines social determinants of health (SDoH) as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”

GC: Healthcare’s pursuit of achieving better care, smarter spending and healthier communities, shows no sign of slowing. Understanding how the SDoH affect patients’ health and wellness will assist patients with achieving better health outcomes with greater cost-effectiveness.

Medical care accounts for approximately 10-20% of the modifiable contributors to health. The SDoH, such as health-related behaviors, socioeconomic factors and environmental factors, account for the remaining 80-90%. Beyond assessing for these factors as part of routine care, clinicians must have the appropriate resources for adjusting a patient’s care plan to address socioeconomic factors that may prevent achieving patients’ health goals, including health literacy, financial instability and food insecurity. With this focus, each part of the industry can partner to meet patient needs and transition to value-based care.

GC: As the industry moves toward value-based care, we must understand the complete patient picture to ensure patients receive the best treatments possible. This stretches us to consider things beyond the medical symptoms with which they present. Ultimately, value-based care initiatives will be achieved by enabling clinicians across a patient’s care team to develop a care plan that focuses on clinical symptoms and the social circumstances that can affect their health. This is critical when treating patients with chronic illnesses and other high-risk conditions.

Here’s an example:

Ms. Smith has diabetes and high blood pressure. Without further assessment of her social circumstances, she is viewed by her care team as being at moderate risk for failing to achieve her health goals. But with the right tools, Ms. Smith’s doctor can identify that she lives in a neighborhood that lacks healthy food options or a safe place to exercise. Because of these factors, Ms. Smith is higher risk. With tools to identify her risk factors paired with solutions to assist her doctor with identifying actionable interventions, Ms. Smith and her care team can personalize her care plan to ensure she achieves her health goals.

GC: When clinicians are provided with pertinent information, from all aspects of a patient’s life, a complete picture of the patient is created and factors that might have been potentially overlooked can be incorporated into the care plan. With this comprehensive view, care teams can work in partnership with patients and their community to incorporate innovative solutions which go beyond medications and procedures to include interventions that address social and economic needs, like early childhood education and development programs, safe access to green space for physical activity, healthy grocery options and in-depth nutrition services.

Leveraging health IT to enable and unleash clinical and community resources to address all factors that contribute to health, clinicians will be empowered to help patients achieve the level of health and well-being they want and deserve.
 

To learn more about Allscripts, visit Allscripts.com/population-health.