Path to Prioritizing SDoH in Whole Person Chronic Care: Q&A series featuring Dr. David B. Alper, DPM, FFPM RCPS (Glasg)

Improving patients' lives requires a compassionate, holistic approach. Taking the time to understand better the social determinants of health (#SDoH) that impact patients provides valuable insights into their challenges, addressing systemic, environmental, and social factors that affect overall well-being.

In this edition of our SDoH Q&A series, we're honored to feature Dr. David B. Alper, DPM, FFPM RCPS (Glasg) , a distinguished leader in podiatric medicine and surgery. With specialties including limb amputation prevention from diabetes and peripheral artery disease (PAD), diabetic and pediatric foot care, and creating and managing public health initiatives, Dr. Alper brings unparalleled expertise to the discussion. He is a trustee on the Board of Trustees for the American Podiatric Medical Association, a member of the Amputation Prevention Alliance at the American Diabetes Association , and an inductee into the Hall Of Fame at Kent State University College of Podiatric Medicine. Understanding social determinants of health is vital in chronic care, and Dr. Alper highlights its role in enhancing patient outcomes.

Q: You led a podiatry practice in Massachusetts for more than three decades. During that time, what experiences did you have specific to supporting patients living with SDoH? Any lessons learned to share?

A: Practicing in an upper-class community like Belmont, Mass., did not isolate me from patients who had social barriers to healthcare. Retirees, advanced senior citizens, and families with "income challenges" often presented challenges regarding their ability to follow prescribed care—be it the cost of medications, transportation to doctor and therapy appointments, co-pays, or language and cultural barriers.?

Perhaps the greatest lesson learned is that giving a patient a prescription for medicine or care in no way means it will be filled—further conversation with the patient before prescribing is necessary so that your care aligns with the patient's ability to comply with your treatment plan.

This discussion should include family members if possible (I often asked patients to bring "another set of ears" to my appointments) and include cultural issues. For example, dietary traditions can be a hurdle. A person living with diabetes and with a Caribbean background will find it hard to remove beans, rice, and plantains from their kitchens. Traditional homeopathic treatments can also run in conflict with prescribed care. For example, I cannot tell you how often I had to instruct people not to soak their feet in bleach. The bottom line is that the more you include the patient in your recommended care, the more likely it will be followed.

Q: You've mentioned, "Amputation prevention is health equity." Can you explain what you mean by that more precisely?

A: The American Diabetes Association (ADA) shares that Black patients are 4 times as likely to have an amputation due to diabetes and PAD. Meanwhile, Latino patients are 2 times as likely, and Indigenous patients are 1.5 times as likely. We also know that 85% of non-traumatic amputations are preventable with early intervention. With a lack of accessible healthcare in poorer and culturally diverse communities, that intervention often does not happen. That's why I am a firm believer that efforts to support amputation prevention resulting from complications with diabetes are an enabler to a more equitable healthcare system.

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

A: The following is a list of key questions that clinicians should consider asking to unearth potential challenges patients may be facing specific to SDoH:

1) Do they have help at home? As in, someone who can monitor their healing progress?

2) Can they afford the cost of the care prescribed (including transportation to and from visits)?

3) Do they understand that some of this care will last their lifetime?

4) Do they have access to basic nutrition that aligns with their condition(s)?

5) Would having instructions and information in another language help with following care instructions? (ADA, as well as hospitals, can provide information in many languages.)

6) Are there any cultural barriers that may prevent the proper care from occurring? (i.e., specific foods)

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

A: SDoH-focused care should be grounded in the following:?

• Clear, consistent communication;
• An understanding of the difference between the daily lives of a typical patient living with diabetes and one who is dealing with SDoH challenges;
• More aggressive initial follow-up to ensure prescribed care is and can be followed and?
• A discussion on the short and long-term projected costs of the prescribed care.

Q: What innovations specific to SDoH do you think hold the greatest promise today?

A: Innovations specific to SDoH must first focus on identifying the breadth of the issue at hand. For example, the ADA and American Hospital Association have created "Heat Maps" that clearly show overlap in the incidence of amputation and income. Sharing this map has resulted in true recognition of the issue of SDoH.

Additional innovations that hold the most promise include the food-is-medicine movement, which helps address the critical need for access and affordability to healthy foods. Finally, a proactive versus reactive approach to vascular and diabetic challenges. It is easy to amputate—it takes more thought to get in there early for a patient and prevent the cause of the amputation.