Path to Prioritizing SDoH in Whole Person Chronic Care: Q&A series featuring Dr. David Kerr, MBChB, DM, FRCPE, FRCP

By delving into the social determinants of health (#SDoH) that impact patients, we gain valuable perspectives on their challenges, addressing systemic, environmental, and social factors that influence overall well-being.

In this edition of this SDoH Q&A series, meet Dr. David Kerr, MBChB, DM, FRCPE, FRCP, who has extensive expertise in the field of diabetes research and advocates for digital health equity. Dr. Kerr is the Director of Digital Health at the Diabetes Technology Society (DTS) and Senior Investigator at the Sutter Center for Health Systems Research. Understanding the profound impact of social determinants of health is crucial in managing chronic care. Dr. Kerr's expertise illuminates the urgency of addressing these factors to improve patient outcomes significantly.

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

A: The poster child chronic condition — where the social determinants of health (SDoH) have a significant influence — is type 2 diabetes. The burden of type 2 diabetes falls disproportionately on communities that are also often facing health disparities. For example, lifestyle interventions remain a cornerstone of modern diabetes care, yet this is often only paid lip service in clinical encounters. As a corollary, there is good evidence that adherence to a prescribed drug regimen among individuals living with a chronic disease such as type 2 diabetes is less than optimal, increasing the risk of adverse physical and mental health outcomes over time. Clinicians, therefore, need to set aside time to understand patients' social gradient — where they live, what access they have to things that most of us take for granted (internet, a local pharmacy, a supermarket offering fresh, affordable produce, a caregiver, etc.). This is a time-consuming endeavor, but it is necessary, and this is where artificial intelligence (AI) could make a substantial difference.

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

A: Healthcare in the U.S. is inequitable. The current state of U.S. healthcare is a legacy of a system created to accommodate cost shifting in a for-profit environment against a backdrop of wealth inequality, policy gaps, and a diaspora with varying needs. Any organization providing healthcare to individuals living with a chronic disease needs to consider three components: reimagining care delivery, investing in people, and ensuring trust in organizational leadership. Further, to prioritize the SDoH needs for people living with chronic disease, an organization needs to be bold enough to look inward and ask itself — "are the outcomes from the care we offer equitable." Audit of performance is not a one-off approach; this must be continuous, and the results must be compared with those of other similar organizations to ensure there is progress. For patients living with a chronic disease, clinicians should view the care provided from their perspective by considering three aspects: their ability to access care, their experience of care, and, most importantly, from the perspective of SDoH, their bandwidth to engage with the demands of care.

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

A: Trust is the foundation. The absence of trust in the healthcare system is based on historical precedents, and gaining and maintaining trust takes time. Trust is built by ensuring access, using culturally congruent and inclusive language, and ensuring that individual patients can understand and assess the balance between their cost and time burden related to the disease versus their perceived return on this investment. Good clinicians should aspire to develop self-efficacy for patients under their care. For example, having access to care or services does not guarantee success for the user, just as a weighing scale or a diet plan does not guarantee success with weight loss. Good clinicians focus on the uniqueness of the individual patient — this creates therapeutic empathy, which builds and maintains trust. Up to this point, the demands of the electronic medical record have had a negative impact on this. Hopefully, this will be turned around as large language models are integrated into healthcare systems to deal with the mundane aspects of data collection, creating more time for clinicians to be clinicians in the traditional sense.

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

A: The current approach to care creates barriers for patients to communicate SDoH needs to their care providers. In addition, the presence of discordant health beliefs is frequently under-appreciated by clinicians. For example, among Black Americans with diabetes, discordant health beliefs are common and associated with low use of virtual healthcare facilities, worse diabetes self-care, and suboptimal glycemic control. Discordant beliefs also create a barrier to successful changes in behavior. Within a clinical consultation, the meaning and context of what is said must be understood in order for a message to be successfully conveyed. Patients may have the technical expertise to perform a prescribed task, but the task may be carried out incorrectly without accurate interpretation. Words may not be understood during a consultation because the clinician uses medical jargon. Further, even if the words are understood, the meaning may not be. The message can be lost if the content does not consider influences outside the usual medical domain — experiential, familial, and cultural factors. In other words, information may not be actionable due to outside influences. Therefore, there is a need to ensure that the experience of care considers the numeracy, literacy, and an understanding of patient health beliefs and that actionable information is offered. Embedding assessments of understanding will require specific training for professionals. For patients, the creation of pre-clinic checklists could lower the barrier to discussions around SDoH.

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??

A: In general terms, primary care remains the most authoritative and effective resource. Any organization providing care should be bold enough to look at their data to examine the influence of SDoH on outcomes for patients under their care. In turn, these same organizations should ensure that the results from these inquiries are in the public domain. If not, we should be asking, why not? In the absence of this information, support can be provided by local patient-first organizations, and by expert patients. The first ports of call are often the internet and social media. Patients need to be aware of the risk of disinformation (i.e., fake news), which, sadly in relation to living with a chronic disease, is ubiquitous.

Q: When clinicians are more overburdened than ever, how can they best prioritize SDoH in today's shortened care visits and beyond??

A: This is about clinician education. We know that physical and mental health outcomes are influenced by genetics, environmental exposures, and healthcare delivery, but most of the influence is from the SDoH. In other words, the nature and nurture source code contributes to the outcomes of any chronic disease. It is also important to avoid nihilism – the mistaken belief that SDoH influences are unchanging and life-long. Clinicians need access to new knowledge, time, tools, and rewards for embracing the sociology of care. If successful, the benefits to patients, healthcare systems, society, and the clinicians themselves will be enormous.

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

A: Two words — artificial intelligence. Recognition of the importance of SDoH on the risk of developing a chronic disease and the associated short- and long-term outcomes has grown exponentially, especially as a consequence of the recent pandemic. However, the promise of AI is as a driver of change. It will create more time for human-to-human interaction, which is fundamental to the art of medicine. A few examples of where AI can score immediate successes include: (i) The ability to offload mundane tasks such as ordering tests and appointments, populating the electronic health record, billing and dealing with insurance claims, all using large language models that capture conversations automatically; (ii) Screening for disease (e.g., screening for diabetic retinopathy); (iii) Answering questions through digital patient portals; (iv) Providing evidence-based guidance for clinicians; (v) Monitoring patients at home to reduce the burden on acute hospital care; and (vi) Incorporating SDoH data into algorithms that will be used increasingly to understand better the heterogeneity of chronic disease leading to more personalized interventions.