Path to Prioritizing SDoH in Whole Person Chronic Care: Q&A series featuring Dr. Tom Hardiman

A new installment of the Q&A series on prioritizing social determinants of health in #chroniccare is here, and we're featuring Tom Hardiman , D.P.M., an advisor to the American Diabetes Association and member of the American Limb Preservation Society.?

Dr. Hardiman emphasizes the urgent necessity of revolutionizing medical practices to ensure patients feel valued, receive proper care, and achieve better outcomes. As he eloquently discusses below, if our healthcare system's purpose is genuinely promoting health, then it is currently failing and unsustainable.?

This is precisely why it becomes vital for all stakeholders to prioritize the transformative changes required in medicine, particularly in embracing the significance of Social Determinants of Health (#SDoH ).?

Dive deeper into his profound insights and invaluable guidance on how we can address and enhance SDoH in comprehensive chronic care.

Q: What should clinicians be asking their patients living with chronic conditions to better understand the challenges they are facing specific to SDoH?

Asking patients about their lives, working situation, education, and family is not a new concept. Clinicians have done this routinely forever. What is new over the last 5 to 10 years is that we are all starting to ask the same questions, framed in the same way, so the answers provide better-quality information and data. We also now appreciate how much impact these non-clinical variables have on outcomes. But getting dependable and straightforward information from patients can be difficult if a trusting and caring relationship does not exist.?

In 2012 an article appeared in the New England Journal of Medicine by Michael Barry, MD, and Susan Edgman-Levitan in which they introduced the concept of asking patients, “What matters to you?”, in addition to “What is the matter?”. This type of questioning expresses caring and concern and encourages the patient to trust the clinician and staff, and it leads to further discussion about specific SDoH issues. As Dr. David Armstrong often reminds us when sharing this quote attributed to Theodore Rosevelt, “People don’t care how much you know until they know how much you care.” Once people know their clinician respects them and sees and hears them as a person and genuinely cares, they will more likely share details of their lives with them. How you ask a question is sometimes more important than what you ask, and there are many excellent SDoH question templates available online.

Q: Are there any approaches your organization or other leading organizations in healthcare are taking to prioritize SDoH needs for people living with chronic diseases?

The two organizations that I most closely follow are the American Diabetes Association and the American Podiatric Medical Association (APMA) Medical Association. I think both groups have done a commendable job educating their professional members about the importance of SDoH by offering great online content, webinars, published articles, and live conferences on this multifaceted subject. Currently, almost 70% of our adult population is living with at least one chronic health condition. So the bottom line is that it is high time to prioritize SDoH for everyone. Because we have not done this yet in the U.S., unlike comparable countries, we now suffer from the highest disease burden compared to any other population. We spend more on healthcare than anyone in the world, yet we have the worst outcomes, according to the latest Commonwealth Fund Report. If the purpose of our healthcare system is to actually help people be healthy, we are failing miserably, and it is unsustainable. That is why we need to make changing the way we do things in medicine, like taking SDoH seriously, an absolute very high priority for all stakeholders.

Q: What should an SDoH-first approach to care actually look and feel like for a patient?

An SDoH-first approach to care should feel very natural and authentic, like a nice conversation, not at all forced or uncomfortable. It should be like a great consumer retail or service experience when you can appreciate the attention to detail and experience some empathy from the other person. That somehow translates to a feeling of trust, appreciation, and gratitude. Patients are people first, not just an interesting problem to be diagnosed. After all, we all want to feel seen and heard. It is nice when someone takes the time to try to get to know us and seems to value our thoughts and respect our feelings. Hopefully, a sincere SDoH-first approach would be a means to that end. To the patient, it should look and feel like these caregivers actually really and truly care about them as an individual.

Q: How can patients best communicate their SDoH needs to their care providers?

In January 2021, the American Board of Internal Medicine conducted a patient (and doctor) survey on trust in a clinical setting. Turns out that patients trust 85% of nurses, 84% of doctors, and 72% of hospitals. In order for communication to be effective, trust must be established and prioritized between patients and their caregivers. In some clinical situations, when stress, fear, physical pain, uncertainty, confusion, and anxiety are present, trust can be difficult to establish. But it is essential because once trust is established, people can then feel safe communicating all of their questions, concerns, and SDoH needs to their providers. Some people may feel intimidated, guilty, embarrassed, or ashamed sharing details of their SDoH status, so a safe, trusting, and respectful relationship between patient and provider is absolutely necessary to break down barriers.

Q: If a person is not receiving the care they need related to SDoH, where else can they go for support beyond their primary care provider and team of care specialists?

Only 20% of health outcomes are determined by healthcare access and the quality of care that a person receives during their lifetime. The other four domains of SDoH determine the remaining 80%, and they are: economic stability, education access and quality, social and community context, and neighborhood/built environment. Patients, primary care providers, and their staff need to be aware of the other four SDoH domains — and also need to have a working knowledge of the social service system in order to help their patients navigate that system. Designating a “navigator” to help a patient with getting their SDoH needs addressed is very helpful. Besides the primary care provider’s office, government- and community-based agencies are sources for SDoH help, as well as a local council on aging, a faith-based group or church, or an employer’s HR department might all be able to assist people with their SDoH needs. No one should feel that they are traveling on their SDoH journey alone.

Q: At a time when clinicians are more overburdened than ever, how can they best prioritize SDoH in the shortened care visit of today and beyond?

In order to best address and prioritize SDoH, clinicians have to adjust their workflow to integrate the actual conversation needed around SDoH needs. This will require a streamlined system, and that probably means delegating that responsibility to another clinical team member. At some point, there should also be financial incentives available to encourage providers to acquire SDoH information. Some patients will be comfortable completing SDoH questionnaires through a patient portal or on an iPad at the point of care location. Others will require more help. Using standardized templates to acquire SDoH information is also important and very helpful, and they are readily available to download. One I really like is available from CMS . Once everyone can accept the fact that 80% of health is determined by variables outside the clinical setting, then the extreme importance of gathering SDoH information can be better appreciated by patients and providers alike, and this will lead to it being given the priority it deserves.

Q: What innovations specific to SDoH do you think hold the greatest promise today and into the next 5 years?

Digital health technology got a baptism by fire during the COVID-19 pandemic. Out of necessity, patients and providers used whatever means necessary to share health information and provide care. Some things worked well, others not so much. Even though a lot of care has returned to in-person, digital health technologies have gained a much broader acceptance and use since the onset of the pandemic. The best #digitalhealth innovations are the ones that people can easily understand and use on a daily or very frequent basis. These tools need to fit into their lifestyle and routine and enhance and strengthen the working relationship with their care providers. Much of health takes place at home, so getting data in real time directly from a patient’s home creates familiarity and allows for timely intervention and management. In the next five years, ChatGPT and AI will certainly help with disseminating information, population health, patient education, and diagnostics. Digital health tools clearly have the potential to positively impact healthcare, decrease disparities, and increase equity in healthcare.? That is very good news indeed!