Social Determinants of Health Programs to Support Whole Patient Care

Written by Kola Omotade, MHA, and Aroub Khleif, PhD

Picture this common scenario: Martin Smith comes into a Houston Methodist (HM) hospital and is admitted by the Emergency Department (ED). Martin spends five days in the hospital which includes diagnostic testing, frequent visits from his care team and three square meals a day. On the third day of his stay, Martin is diagnosed with stage 3 colorectal cancer. His care team reassures him that with treatment, this cancer is treatable. His treatment plan includes a partial colectomy to remove some of his colon followed by adjuvant chemotherapy. However, what the care team does not know is that Martin currently does not have a stable place to live, does not own a car and, as a result, is also experiencing days of food insecurity. For a patient like Martin, adhering to the recommended treatment plan to cure his cancer would be difficult. Not because he does not want to, but because his current quality of life does not allow this. When a patient is dealing with social determinants of health (SDOH) that adversely impact their lives, they are less likely to remain compliant with the needs associated with healing.

SDOH encompass social, behavioral, economic, and environmental conditions that affect an individual’s health outcomes and risks such as race, gender, housing/living conditions, transportation availability, nutrition insecurity, violence, financial strain, etc. – all of which are fundamental contributors that impact one’s quality of life. In order to care for a patient holistically, it is important to understand if they are experiencing any social factors that could further impact their health.

As part of HM’s commitment to providing unparalleled, personalized care and service for all patients, our system established a Health Equity Steering Committee to address social factors impacting the health and wellness of our patient population. The SDOH subcommittee is a smaller group made up of steering committee members and other internal stakeholders from multidisciplinary teams across the health system that play a role in centralizing HM’s efforts in addressing patients’ social needs.

One way that HM is addressing health disparities is by leveraging tools and data within our electronic medical record (EMR) system, Epic, and external data from outside organizations to screen, identify and address patients’ risks for social determinants and connect them with the appropriate community resources to receive assistance. This is part of a multi-phased approach rooted in accessibility to provide holistic care for our patients and includes:

• Use of predictive analytics and risk stratification models to identify potential risk and social barriers that impacts patients receiving care and their hospital discharge
• Integration and standardization into clinical workflows within the EMR to facilitate real-time patient-centric care across the care continuum
• Leveraging HM’s patient portal to provide alternate opportunities to improve patient care and allow patients to self-report health indicators and social determinants
• Direct EMR integrations with other systems to support closed-loop referrals with aligned Community Benefit Organizations (CBOs)
• Exchange different data sources across organizations to support comprehensive care through different health information exchange connections

As a health care delivery system, we have strong partnerships with CBOs within Greater Houston that have the tools, resources, and expertise to assist patients who screen high risk for specific SDOH such as housing instability, food insecurity, intimate partner violence and lack of transportation. Making this intentional connection to these organizations utilizing our EMR will facilitate this concept of a closed-loop referral, the process by which partner organizations can transmit data back to HM to provide an update on the outcome of the referral. This information will provide insight on the impact of making the connection and, furthermore, allow HM to understand if a patient’s risk has decreased over time as a result of this assistance.

There has been increased research and global recognition regarding the role social determinants of health has in improving daily function, quality of life, and reducing health disparities. The ability to identify SDOH using our EMR allows our physicians, nurses, case management/social work teams and additional patient facing staff to incorporate this into their existing workflows. By working with our partner organizations, we are better positioned to actually address the identified needs, and by tracking the results of these outcomes, we will be able to better understand a patient’s story. These efforts continue to allow HM to take care of the whole patient and help patients like Martin improve their health outcomes, which is a vital step towards achieving health equity for all patients.