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

Welcome to our latest in-depth Q&A series featuring Dr. Christopher Steele, MD, MPH, Assistant Professor of Medicine at the University of Connecticut School of Medicine, co-founder of UConn Health Leaders, and a dedicated advocate for addressing social determinants of health (#SDoH) in chronic care. With a medical degree and a Master of Public Health from the University of Connecticut, along with training in internal medicine at Johns Hopkins, Dr. Steele established himself as a pivotal figure in the mission to weave SDoH into the fabric of patient-centric healthcare.

As a clinician educator for the Department of Medicine at UConn Health, he trains learners to provide more equitable healthcare by addressing the social determinants of health in their communities. He has presented extensively on the topic. In this discussion, we aim to explore Dr. Steele's insights on strategies that embody an SDoH-first approach to care and highlight innovative steps in prioritizing these essential needs.

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

A:?Before medical school, I first became aware of health inequities when I volunteered as a patient education coordinator at a free clinic in New Haven, Connecticut. This place was a lifeline for the uninsured in the area, many of whom were immigrants who mainly spoke Spanish.?

Early on, I was struck by the number of folks struggling with uncontrolled diabetes who wanted to get better but just could not seem to manage their condition. The more I got to know the patients, the clearer it became that it was not a lack of willpower but a lack of resources. Diabetes was not just a health issue; it was a social issue — things like not being able to afford insulin or the right kind of food for a diabetic diet were common stories driving their poor control. Despite the social determinants of health (SDoH) driving these inequities, I saw firsthand that many doctors often lacked the skills to discuss, identify, or address them appropriately.

It really bothered me to see these gaps — how these social factors created such unfair differences in health outcomes. It did not sit right with me that my patients, and even the students I worked with, were getting shortchanged. I was hopeful that medicine could find ways to address one's SDoH in medical care to close those unfair health gaps and, at the same time, forge a stronger, more personal link between patients and their doctors. So, I decided to make it my career goal to bridge this gap in medical education.?

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

A:?William Osler, MD, the father of modern medicine, said it best: "The good physician treats the disease; the great physician treats the patient who has the disease." Medicine is not just about treating illness but about understanding and supporting a patient's whole life situation.?

As healthcare providers, adopting an SDoH-first approach to care would involve organizations making it a mission to get to know their patients for more than just their health conditions.

Imagine you walk into a clinic where they really get the big picture of your life. First, they'd ask about more than just your health — they'd want to know where you live, your job, your family, and if you're getting enough to eat. It's like they're piecing together a full story, not just focusing on the symptoms.

Then, the treatment plan they devise is super tailored to you. Say you have diabetes but live somewhere without good grocery stores—they'd help you figure out how to get the right foods to you. It is not just doctors; you'd have a whole team, such as social workers, pharmacists, and other healthcare providers, who understand the different parts of your life affecting your health and could connect you to community organizations to address your needs.?

Everything about the care would feel respectful and sensitive to your background and culture. They would keep checking in on you, not just about your medical issues, but ensuring you're okay on all fronts.?

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

A:?In my journey, I've seen many students witness these inequities but do not get the chance to really dive in and make a difference. Many of them desire meaningful clinical experiences, yet there is no means for them to have such an impact or learn how to make that difference.

Our organization decided to tackle this head-on. We created the?UConn Health Leaders (UCHL)?program, which aims to train the next generation of professionals to identify and address social determinants of health while awaiting clinical care. Our approach mixes a curriculum with real, on-the-ground experience. Volunteers from our program get to screen patients for SDoH in the UConn clinics while waiting to be seen. Our smart screening tool points them to local resources if they identify an unmet need. The volunteer helps them engage during that visit by directly contacting the organization through a warm handoff method.?

UCHL not only addresses the practice gap many clinics face appropriately screening for SDoH but also provides skills necessary for these volunteers to one day address these concerns when they are practicing.?

Q: Can you tell us more about the University of Connecticut Health Leaders program you lead and its impact?

A:?UCHL's mission is to improve healthcare delivery by training the next generation of professionals to identify and address unmet social needs patients face in their communities. Each volunteer completes 10 four-hour shifts a semester and approaches patients with a smart survey that generates a script for them to ask common SDoH questions. For those who receive positive survey results indicating SDoH challenges, the survey helps provide localized resources in their area that address their needs.?

Over a three-year period, UCHL trained 303 volunteers to screen 8,994 patients to identify 5,945 patients (66.1%) with at least one social risk factor. Of that population, they were able to address 2,115 unique social needs through connection to community resources! As important, each student now has the skills and knowledge necessary to begin addressing the SDoH for patients while practicing.?

Success in the program lies in the leadership team, which is composed of over a dozen current medical students and students awaiting acceptance into graduate medical training. This team is the heart of the organization and plays a significant role in selecting, training, and mentoring all team members. This leadership model has created a community of students who want to stay. Of those who were part of our leadership before being accepted into medical school, eight of the 10 attend or will attend UConn School of Medicine. Many of these students are starting their own projects to address other health inequities in our communities, such as improving cancer screening rates or working with specific vulnerable populations.

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

A:?Healthcare providers must consider more than just clinical symptoms when managing patients with chronic conditions. The best way to identify any unmet social needs is to use standardized screening tools such as questionnaires with validated questions. It is important to use a validated questionnaire, as these questions are known to both accurately identify and capture people with unmet needs. Some examples of questionnaires are?PRAPARE Screening Tool?and the?WellRx Questionnaire. Many of these questionnaires ask about topics such as food insecurity, level of education, housing stability, medical transportation, and other key topics such as finances related to utilities and interpersonal safety.?

After knowing what questions should be asked, the next step is making sure patients are asked! Screening should be both succinct but also administered to everyone.?Nearly two in every three adults?will screen positive for experiencing at least one unmet need annually, with about one in four Americans stating that it impacts their access to healthcare. It is also important to ask during all visits as these needs can fluctuate. In most circumstances, these questions can be answered in a few minutes while the patient is either waiting to be seen or by someone from the healthcare team.?

Q: What role can community organizations, such as churches, etc., play in supporting people facing SDoH challenges?

A:?Community organizations are the unsung heroes when it comes to addressing social determinants of health. They are on the ground, right in the heart of the community, so they've got a real grassroots advantage.?

Take a church, for example. It can be a hub for wellness programs, from running a food pantry to helping folks get to their doctor's appointments. They're good at rallying volunteers for these sorts of things, and since they often have space available, they can host health fairs or workshops where people can learn about managing conditions like diabetes or high blood pressure. Some of the most successful impacts to date, such as the?Barbershop Blood Pressure Program, are the result of community involvement.

They are also great at connecting people with support networks, which is huge. Sometimes, knowing someone else is in your corner can make all the difference when facing tough times. That sense of belonging and support can be a real game-changer for the mental and emotional health of those who are experiencing unmet social needs.

In a nutshell, these organizations play probably the most important part in making healthy living accessible for everyone, especially those who might otherwise slip through the cracks.

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

A:?We are making great strides with technology to tackle social needs in our community, but there is still room for improvement. For instance, stores now accept SNAP for online grocery shopping to help people in food deserts access better-quality foods. Though this is a step in the right direction, you still need the internet and some kind of device to utilize it. Even when you can get online, figuring out the healthy stuff to buy can be overwhelming.

Looking ahead, though, I have got to hope that artificial intelligence (AI) will be a game-changer in the next five years. I look at AI as an assistant to address barriers preventing patients from accessing care or resources. There are already advancements in AI that can whip up a shopping list that fits your budget and health needs, down to the carbs you need in every meal. It could even be utilized in healthcare, asking the right questions to pinpoint exactly what social support a patient requires. For instance, if it identifies a patient with housing instability, AI could delineate if they are currently homeless or at risk of losing housing and tailor its resource connection based on the response.?