Path to Prioritizing SDoH in Whole Person Chronic Care: Q&A series featuring Dr. Laura Gottlieb, MD, MPH

To enhance patients' lives, we must advocate for a compassionate and comprehensive approach to their care. By immersing ourselves in understanding the social determinants of health (#SDoH), we gain valuable insights into their unique hurdles. This approach goes beyond addressing symptoms by tackling systemic, environmental, and social elements affecting overall well-being.

In this edition of our SDoH Q&A series, we are honored to discuss this vital topic with Dr. Laura Gottlieb , MD, MPH. Dr. Gottlieb is the co-director of Social Interventions Research and Evaluation Network (SIREN), a national research acceleration and translation institute that brings together researchers from across the U.S. to catalyze research at the intersection of social and medical care. She is also a professor of family and community medicine at the University of California, San Francisco.

Q: What personally led you to focus on health inequity and SDoH?

A: I walked into medicine through the door of HIV care in the 1990s, largely working with people experiencing homelessness, living with substance use disorders, or otherwise facing major poverty-related barriers to health and healthcare access. It was a devastating example of how power and politics shaped dramatic health inequities like many healthcare issues. The rest of my career just kind of unfolded from there. That experience in HIV testing led me to medical school: I loved connecting with people in one-on-one healthcare encounters. Eventually, as a doctor, I also witnessed that even when we aim to help, we often do much harm. The fallout from that despair was that I entered a Robert Wood Johnson Foundation fellowship program, expecting to learn everything I could about social determinants of health and then leave medicine entirely. Instead, my mentors in fellowship encouraged me to stay in medicine and use my M.D. to help bring the conversation about social determinants more squarely into medicine. Et voilà. Here I am.

Q: Can you tell us more about the Social Interventions Research and Evaluation Network (SIREN)?

A: In 2016, we convened a group of researchers across many branches of medicine to ask what would help them understand the impacts of integrating social and medical care delivery. These were people at the leading edge of social care research; many had never met the other folks in the room. There was not yet a defined health services research field focused on social care, per se. Those people asked us to create a hub for research in this space. So that's just what we did—and those folks continue to be many of our closest advisors (at least, those who haven't retired!).

SIREN is a place where we conduct, collect, synthesize, and catalyze research on social and medical care integration—and then we try to put it in the hands of people who can use it, like policymakers and healthcare leaders, using a wide range of dissemination strategies. We maintain a free and easily searchable online library; we distribute a monthly newsletter; we do many public presentations; we run conferences; and we publish podcasts, papers, and reports. Our team is small and mighty! You can learn more about us and sign up for our newsletter at sirenetwork.ucsf.edu.?

Q: What SDoH-specific work and/or research are you leading at UCSF that you are most excited about or hopeful about? Is there anything you are worried about??

A: I think right now, I'm excited to be thinking aloud with amazing colleagues from across the U.S. and many countries abroad about the many ways better integration across health and social care sectors could lead to meaningful improvements in health and health equity. It's great that we're seeing technology innovators investing in social care data dashboards and policymakers designing quality measures for care integration. In the same breath, though, I have many "be careful what you wish for" feelings right now. Because I see a lot of innovation and enthusiasm without careful, deliberate efforts to ensure these innovations are "meaningful." For example, we now see a lot of money going into technology to facilitate efforts to refer patients with social needs to social services.

Still, we haven't seen a lot of data showing that technology actually leads to decreases in social risks and improvements in health or health equity. In another example, we see a lot of energy expended to meet social risk screening quality measures. Still, less attention is paid to the quality of patient experiences around screening, particularly for minority patients who — with good reason — may feel unsafe in many healthcare environments.?

One project our team is working on is developing measures for the patient's social care experience. If we get these measures right, I hope they will counter our current disproportionate focus on the quantity rather than quality of social risk screening and related interventions.?

Q: What should clinicians ask their patients living with chronic conditions to understand better the challenges they face specific to SDoH?

A: Across multiple studies on how health professionals feel about asking patients about social risk factors, we've heard that clinical staff are uncomfortable asking about social risks when they don't feel like they can "cure" or "resolve" social adversity. But in 2019, we did a big study across the U.S. where we asked patients how they feel about social risk screening, and we heard that, by and large, patients don't expect their healthcare providers to solve all the social barriers they face—they want them to know about them.?

Patients want their clinicians not to turn them away from the clinic for being late after they raced to take three buses to get there. They want them to understand that they couldn't take all the medications as prescribed since the co-pay was too expensive. Patients know intimately how social factors affect their health, their ability to eat nutritious food, and their ability to get enough sleep. And they want their provider team to care that those are real obstacles for them. Of course, connecting patients with effective social services can be an important component of caring, but the lack of compassionate care is where I think we've fundamentally lost our way. And a healthcare system focused on making money rather than achieving health probably won't help us get compassion back into care.?

Q: Are there any innovative approaches your organization is taking to prioritize SDoH needs for people living with chronic diseases?

A: We have an exciting partnership with OCHIN, which provides a single instance of the Epic EHR platform for community-based health organizations across the U.S. Along with AHRQ grant support, we've been exploring ways to leverage the growing availability of social risk data at the point of care to improve health for people living with chronic diseases. In that grant-funded study, we've been designing and testing point-of-care decision support tools that flag patients with diabetes and/or hypertension who report one or more social risk factors. Those tools then suggest how to improve care for particular patients, e.g., by modifying insulin treatment to match food availability (in patients who are food insecure) or planning phone rather than internet-based or in-person follow-up (in patients with internet and/or transportation insecurity). None of this is to the exclusion of connecting patients with social services or resources to reduce social barriers; we're also trying to facilitate care changes to accommodate the real-life barriers that patients face to accessing care and benefiting from care.?

That study is focused on diabetes and hypertension, but I think those are just influential case studies for eventually looking at other diseases—and, in many cases, prevention, like cancer screening or vaccine uptake. In other work, we've been using artificial intelligence, including large language models, to make recommendations for impactful social care interventions—and maybe even populate social referrals–so the social care workforce can spend more time with patients and less on administrative activities. Though the EHR and other health I.T. have been touted as a big medical advance, I often feel like we fail to harness technology for good. I think we're all still in the big EHR "trough of disillusionment," frankly. I'm hoping we can figure out how to make health I.T. part of precision social medicine in the future.

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

A: I don't think that an "SDoH-first" approach is something I would argue for in health care. I would say we need a "patient-first" approach, which translates to eliciting and addressing the priorities of each patient. Sometimes, those priorities may be about getting a mattress or a bus ticket—or maybe getting a job or back into school. Ultimately, I hope that patients in our health system feel they are being cared for by an entire team that can help them on their journey. And, of course, that means the team has to include a lot of different caring people—people who together both help patients feel safe in healthcare settings and who can help them unlock the resources they need to support their health.?

Sometimes those are medical resources, sometimes they are social resources, and usually they are both. From that vantage point, it's easy to argue that healthcare systems are responsible for strengthening opportunities/resources at the community level. They can help them meet those "patient-first" goals. That said, there are many other reasons for healthcare systems to be actors at the community level, including their critical roles as anchor institutions (organizations are cornerstones of community economic development).?