7 minute read

The panel discussion took place on Thursday 19 October 2023 at the CFHA Annual Conference in Phoenix, Arizona. The following questions were given by the moderator, Sentari Minor (EvolvedMD). Other panelists included Pedro Cons (CEO, Adelante Healthcare), Gabriel Jaramillo (Vitalyst Foundation), and Crystal Heiligenthal (Physician Assistant, HonorHealth). I am including only my responses below.

From your standpoint, when you hear “Social Determinants of Health” (SDOH), what does that mean to you?

I think of two things. First, I think of the privileges I have experienced throughout my life and the significant way those privileges have promoted my health and wellbeing. In my life, I have not worried much about housing, education, food security, transportation, or other similar needs. And as a result, my health has allowed me to pursue my personal and professional goals. 

Second, I think about a quote that I heard several years ago from Don Berwick, a pediatrician and healthcare pioneer, said “Healthcare is a weak tool, it’s nearly impotent if we want vitality in populations.” That statement sat me with for several days and afterward I slowly came to grips with the reality that healthcare has serious limitations, that a thirty or sixty minute weekly appointment can only do so much for a patient. This realization helped me understand my frustration as a clinician. Why are some patients not coming back? Why are other patients coming back but repeatedly? That realization was a helpful transition for me.

So, today, I see social determinants of health as the macro-level social contexts, those powerful influences that drive health benefits for some and health penalties for others. SDH also helps me understand that certain government policies, political environments, and economic factors make the jobs of healthcare professionals more difficult. Whether it is enforcing mental health parity laws, encouraging affordable housing, or just simply making internet access a public utility, these macro-level forces play a significant role in determining the health outcomes of our patients and me and you.

But the term SDH can sometimes be so big and so abstract that it is not helpful when we are sitting across the exam room from a patient. There is another term, health-related social needs (HRSN), that started being used in 2011. I like this term because it is patient-focused and helps me recognize the individual-level situations like food insecurity, housing instability, and transportation barriers. It also captures social needs like interpersonal safety and loneliness that are often not captured by SDH.

The term HRSNs also helps me recognize that individuals can still experience problems like poor housing quality or a limited public transit system in a city or community that has significant social and economic resources.  I still believe Don Berwick is right. Healthcare has serious limitations and was never meant to solve the social and economic issues we live in. And these ideas, that we are discussing today, help me to see community and patient health from a systems viewpoint and to imagine how the healthcare system could be so much more successful through changes in the social, political, and economic contexts we live in.   

How is care impacted by SDOH in each of your settings?

My comments will be about individuals involved in the justice system here in Arizona. So, I recently completed a project where my team partnered with the county jail health center and a community healthcare organization to better serve individuals with opioid use disorder who were either in the jail or recently released. Our goal was to create a smooth pathway from the jail health service into the community health service.

Now, incarceration makes it really difficult to manage a chronic condition like opioid use disorder. When individuals with Medicaid enter the jail system, they lose their benefits and it then takes time to restore those benefits. Also, many jails do not offer treatment like buprenorphine for opioid use disorder. When individuals leave the jail, it takes time for them to restore their Medicaid benefits, find stable housing, return to work, and resume their treatment.

For some, a treatment center that prescribes methadone or buprenorphine might be an hour away. On top of it all, they experience intense cravings and likely mental health issues too. We are talking about multiple needs that should be met for this individual to continue their recovery.

So, in our project, we integrated peer navigators into the county jail health system to find and engage with these individuals, provide health information, follow them through their release, and support them in resuming treatment and receiving social services. We experienced multiple challenges.

First, it was hard to find and hire navigators. Part of the issue was that the compensation was not attractive. Navigators do hard work and should be fairly compensated. Second, the patients often lived in neighborhoods that had very limited housing and transportation services.

So, even if we had great navigators and a great care team ready to provide treatment, the patients were not in a living situation to access that treatment. Overall, the project would have been more successful if more of the needs of our patients and navigators were met.

How is integrated care uniquely positioned to tackle social determinants of health?

I will answer the question by describing a state-wide initiative taking place here in Arizona. I will try to make the point that models of integrated care and models of health-related social needs are intertwined. They rely on each other. Integrated care will be more successful when public health and healthcare systems figure out how to better meet the social and economic needs of residents.

Around 2016, Arizona was one of three states that received a Medicaid section 1115 demonstration initiative from the Centers for Medicare and Medicaid Services. CMS basically said “Here is a big chunk of money. We want you to integrate medical and behavioral services in your system and across as many healthcare practices in Arizona as you can”.

The state agency that administers Medicaid in Arizona is called Arizona Health Care Cost Containment System or AHCCCS and they said “OK. We’ll do it!”. AHCCCS then partnered with a team of experts at ASU to build a learning collaborative. From 2017-2022, this collaborative met on a regular basis and learned how to change their practices. A performance dashboard was made available to each practice so they could see how well they were performing on HEDIS measures.

In 2022, CMS came back to Arizona and said “OK. You did a pretty good job. We want to continue the initiative with a new award and this time we want you to focus on health-related social needs”. Arizona said “That sound great! We used HEDIS measures for the first initiative. What measures should we use this time around?” And CMS said “Um. We will get back to you on that question”. They have not gotten back yet. So, that story is not finished. But I am curious to see what metrics they create for addressing social needs.

I am part of the ASU team working with AHCCCS to help the participating clinics. And I have made a few observations during my time on the project about how integrated care teaches us to better address the social needs of our patients.

First, integrated care teaches us to make it easy for patients to access services. One of the reasons patients love integrated care is because they can receive multiple services in the same location! Social services should be packaged the same way. Let’s make it as easy as possible for patients to find and receive the services they need. Perhaps this means a clinic can start offering food vouchers or bus passes.

In one study out of Chicago, clinics automatically generated with one click a list of local resources based on the address of the patient. The list was then given to the patient and a navigator followed up.

Second, integrated care teaches us to collaborate and coordinate. If we are really going to address social needs, then we have to create a stronger partnership between healthcare and community organizations. Some systems have created a closed referral loop that helps them know when a referral to an outside community resource has been received and completed.

Other systems are using what is called an “anchor institution” model. Examples of anchor institutions include organizations like Duke University Health System and Novant Health, which have increased the minimum wage for employees, thereby increasing the financial security of their surrounding communities. Dignity Health has provided loans and lines of credit at or below market rate to support small businesses, affordable housing, and healthy food projects.

Third, integrated care teaches us to reduce stigma and discrimination toward mental and behavioral health. We can do the same thing for social and economic needs. Patients who are struggling with social problems such as homelessness or hunger may be reluctant to seek healthcare because they fear being judged or discriminated against. Integrated healthcare systems can help to create a more welcoming and supportive environment for all patients, regardless of their social circumstances.

Storytelling is so important to this work, please each share impact in action: A case study or story about SDOH and access to care

I once had a patient I will call Julie. When I first met Julie, she lived with her only son and daughter-in-law in a single-wide manufactured home. There was often conflict in the home. Julie had a history of emergency room visits and surgeries for abdominal pain and GI issues.

Sometimes she would experience seizures while sitting in the waiting room of the family medicine practice where I worked. A nurse and a physician would attend to her and bring her back to a waiting room. These seizures often occurred after Julie experienced a fight with her son or another stressful experience.

Julie was referred to me to just “talk”. And we did. We talked about her husband dying when their son was a young boy and about how hard it was to raise her son by herself. She shared how her son meant everything to her and also drove her crazy. She often worried about her health and feared that she would die young.

I asked her to bring her son for family therapy and she did. I later asked if she had ever thought about finding her own place to live. She said no. And then the next session I learned she had found a new place that was quiet and private. Over time the emergency room visits and seizures went away. Julie started visiting her other relatives more often and attending church. She talked about getting a job and exercising more often.

By the time I left the practice for a new job, Julie had accomplished quite a bit in getting her social and economic needs met. Some patients are like Julie. They just need the space and support to take care of their own social needs. Other patients will need ongoing help from a navigator or case manager.