SDOH, Roundtable, and more!

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Social Determinants of Health (SDOH) have been a hot-button topic in recent years, as more studies have brought to light the effect that non-medical factors like housing, access to food, safe communities, etc., have on health outcomes. The following examples of SDOH illustrate some factors that can influence health equity in positive and negative ways:

• Economic stability
• Education level
• Unemployment and/or job insecurity
• Working life conditions
• Access to nutritious foods
• Housing and basic amenities
• Early childhood development
• Social inclusion and non-discrimination
• Access to affordable, quality health services?

While it’s clear that primary care providers can’t fix the factors listed above, studies show that SDOH have a significant impact on health outcomes–as such, medical providers can’t exactly ignore these issues. For example:

• Some studies estimate that SDOH can account for 30–55% of health outcomes.
• 5% of all U.S. adults reported going without healthcare due to transportation barriers in a 2022 Urban Institute survey. As a result, it is estimated that 3.6 million people don’t seek medical care due to transportation issues every year.?

In 2019, 1 in 4 families reported delaying medical care for a severe medical condition due to cost.

Now that you have the background information–let’s dive in. How can you address SDOH to best serve your patients?

?Integrate SDOH screenings.

With the average primary care visit lasting less than 18 minutes, adding another screening to your plate is no easy task. However, integrating SDOH screenings into your visits can help you identify patients who would benefit from additional help with housing, food security, transportation, or other issues. Early detection of these factors can allow for timely interventions, resource referrals, and comprehensive care planning, ultimately improving health outcomes and reducing disparities. On top of that, understanding SDOH helps providers address root causes of health problems, leading to more effective and personalized care.?

Not sure where to start? Use standardized screening tools to identify social determinants affecting patients, such as the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) tool.?

Resource connection and coordination.

By maintaining an updated directory of local community resources and services, providers can refer patients to housing assistance, food banks, transportation services, employment agencies, and educational programs. If you have a care coordinator or social worker on staff, you might be providing this service already. If not, you could make it easier for other staff to provide connection to services by developing and maintaining a directory of community resources and services to refer patients to. Here are a few suggestions:

• You can find a list of food pantries nationwide here and Meals on Wheels delivery locations here. Patients could benefit from using grocery or meal delivery companies such as Instacart, UrbanEats, WalMark+ In-Home Delivery, and many others.?
• Studies also show that food assistance programs like the National School Lunch Program (NSLP); the Women, Infants, and Children (WIC) program; and the Supplemental Nutrition Assistance Program (SNAP) can reduce barriers to accessing food.?
• Additional suggestions include working with your community for local resources such as churches, food banks, etc. Area on Aging in your community should have a list of resources.? You can likely upload these to your EMR so when these issues arise your team can easily print them out as needed.?

Patient-centered care approaches

help address SDOH by tailoring care plans to each individual's unique circumstances and preferences. When patients are actively involved in their care decisions, providers can better understand and address specific SDOH impacting their health, such as housing instability, food insecurity, or lack of transportation. Empowering patients with the education and resources they need to succeed fosters resiliency and ownership over their health. Collaborative care teams–including social workers and community health workers–provide comprehensive support, connecting patients to necessary services. This holistic approach improves health outcomes, enhances patient satisfaction, and promotes health equity by addressing the broader factors influencing health.

Work with implementation partners.

The ideas below are just a few of the ways your practice can work with other organizations and individuals in your community to address SDOH:

• Community Health Workers: Employ community health workers to bridge the gap between healthcare providers and the community, offering education, resources, and support.
• Mobile Health Clinics: Use mobile health units to reach underserved populations, providing access to primary care and resources directly in the community.
• Integrated Behavioral Health: Incorporate mental health services within primary care settings to address psychosocial aspects of SDOH.

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Featured Content This Week

In part one of our series breaking down the impact of SDOH on patient outcomes, we reinforced the importance of identifying, assessing, and addressing social risks that affect patient well-being.

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