Path to Prioritizing SDoH in Whole Person Chronic Care: Q&A series featuring Philip Middleton, Independent SDoH and Health Equity Consultant

Improving patients' lives requires a compassionate, holistic approach. Taking the time to understand better the social determinants of health (#SDoH) 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 Philip Middleton , Independent SDoH and Health Equity Consultant, who has more than 29 years of experience in healthcare consulting, with much of that time focused on work specific to Medicare Advantage (MA) and the ACO REACH model. He has designed and implemented successful social determinants of health (SDoH) and health equity programs that break down barriers to care for seniors. Philip has a passion for optimizing senior care and ensuring all have access to high-quality, cost-effective, and equitable care. Understanding SDoH is crucial in chronic care, and I'm excited for Philip to share his insights on improving patient outcomes.

Q: Can you tell us a bit about the work you lead and how it helps patients facing SDoH challenges?

A: In 2022, Medicare announced a change for 2023 in the name of the Direct Contracting Entity (DCE) program to ACO REACH with a new emphasis on social determinants of health (SDoH) – health equity. This required a shift to focus more on health equity through a Medicare-approved health equity plan, which I was able to write in collaboration with analytics, clinical, and operations. The plan highlighted a subset population we wanted to follow and measure outcomes to see if our efforts to increase annual wellness exams and lower readmissions would improve the patient's health outcomes. Next, we implemented a healthy equity intake assessment, asking patients a series of questions addressing language barriers to healthcare, housing stability, food insecurity, transportation barriers, and general safety. Based on the response, we follow up with patients within 48 hours to better understand their disparity and work with them on a long-term community-based resource. In addition to our SDoH – health equity efforts, we also provided short- and long-term nurse case management and patient outreach to make sure the patients have what they need to be compliant with their care plan. We were able to increase the quality of care and lower the cost of care through these services.?????

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

A: Unfortunately, many of the patients needing help feel left behind by "the system" and may be leery or suspicious of anyone now telling them they are here to help. The patient interaction must start with the primary care doctor's endorsement and then be followed with dignity, respect, and clarity as to why they are being contacted. Once patients understand why they are being contacted, there needs to be an explainable path to how they will be helped. This authentic interaction may ease their mistrust, which allows patients to explain their needs further. Once the needs are identified, then there must be some sort of temporary relief. For example, if the patient is food insecure, we must be able to offer immediate temporary relief with access to food. I have negotiated a national contract with "heat & eat" meals for patients who are not able to prepare their own food, for example. I've also set in place an agreement with a national fresh produce and pantry staple supplier. These solutions are intended to be temporary while working with the patient on a long-term community-based resource.????

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

A: There are three nationally recognized health equity assessments — AHC, Prepare, and North Carolina —? that can be used as a stand-alone or as a template that can be modified with questions specific to the practice or health system's patient population. The assessment is best offered at the point of contact when the patient is in the office or facility. It can be offered in different ways, such as electronically on an iPad or paper-based, and it can be done telephonically for patients who are calling the office. The assessment can also be mailed to patients to fill out and mailed back or brought in with them at their next appointment. I've found making the assessment part of the annual paperwork we use each year most effective.??

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: There are many local, regional, and national organizations available to patients of all ages. Specific to seniors, for example, there is AARP, Family Caregiver Alliance, National Council on Aging, Meals on Wheels, and the Alliance for Retired Americans. Many of these patients feel alone and defeated. They need someone to listen to them and make a few calls with them. This is where a social worker network proves extremely helpful. Many resources are not obvious. It could be with a local church that does not advertise their assistance outside their congregation. The power of local knowledge is time-saving and impactful.

Q: How can the healthcare industry move from talking about SDoH challenges to actually providing solutions for problems like food insecurity, affordable transportation, etc.?

A: Healthcare providers are overburdened and overwhelmed. They do not have the bandwidth to add more to their already overbooked day. Until it is mandated, it will not get done. Make a health equity intake assessment mandatory for all practices with the option for a patient to decline participation, and then we will see this effort get more attention.??