Those of us in health care understand that the pandemic represents just one more example of the disproportionately negative impact of health issues on people of color. As stated in a 2017 National Institutes of Health report, “For racial and ethnic minorities in the United States, health disparities take on many forms, including higher rates of chronic disease and premature death compared to the rates among whites.” The current situation reinforces the importance of confronting racial and ethnic disparities in health status. In working to close these gaps, we can leverage the evolving focus on social determinants of health (SDoH) as the foundation of this effort.
As physicians, we were all trained in medical school to take a complete medical history, including a social history. Unfortunately, for many of us, social history focused mainly on tobacco, alcohol, and drug use. Beyond that, social history emphasized identifying factors that might help lead to a diagnosis, such as potential exposure to harmful substances or contagions. So, for example, in a child with constipation and behavioral changes, you might ask about housing to assess the likelihood of lead poisoning.
In that context, it’s not surprising to see health care providers struggling to both understand and effectively capture SDoH information on their patients. However, if we are to effectively intervene to reduce health disparities, we need to understand SDoH not just to make a diagnosis but to ensure that patients have the resources, knowledge, and life circumstances that enable them to manage their health. While it’s important to know if a patient is at risk for lead poisoning, it’s also critical to know if they can refrigerate their insulin reliably or if their work situation allows them to take time for an appointment. Do they have transportation challenges or financial constraints creating barriers to care?
Providers may be hesitant to collect this information when they lack the knowledge and resources to help. Most offices don’t have a social worker to provide the kind of support a patient might need to address housing instability, transportation problems, or employment challenges. Community health clinics (CHC’s) may be well-positioned to provide a model for integrating this capability. They are on the front lines of providing health care services to our most vulnerable populations, and close to 2/3 of their patients comprise racial and ethnic minorities.
It is therefore not surprising that they’ve recognized the need for identifying and managing SDoH. The National Association of Community Health Centers has played a significant leadership role by developing the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). This tool enables a structured approach for capturing SDoH information, and fortunately, the PRAPARE template exists for several EHRs.
The greater challenge with SDoH involves the integration of effective social service interventions with health care. This is clearly an area of intense interest as a quick search on the internet revealed over 3.2 million results for “integration of social services with health care.”
Indeed, many promising initiatives are being implemented. In Boston, a housing intervention program for “medically complex” families with unstable housing demonstrated improved health for children and improved mental health for parents in the six months post-intervention in a small randomized controlled trial (RCT). The Veterans Administration, after incorporating social workers into primary care practices observed among high-risk patients, a 4.4 percent decrease in the number of veterans with hospital admissions and a three percent decrease in those with emergency department visits. Area Agencies on Aging have long been partnering with health care organizations to address social needs, and survey data collected from 2008-2013 showed a $136 reduction in average annual Medicare spending per beneficiary for those counties where agencies for the aging partnered with a hospital.
Unfortunately, most of these promising stories are based on observational data or very small, unreplicated randomized trials. Larger, well-designed studies are sparse and often fail to demonstrate benefit. The Camden Coalition in New Jersey did one such trial. They randomized 800 “high utilizer” hospitalized patients with complex medical and social challenges, and the intervention group received several months of visits post-discharge by a team of nurses, social workers, and community health workers to coordinate outpatient care and link them with social services. While there was a 38 percent drop in admissions in the six months post-intervention compared to the six months prior, there was no difference between the intervention and control group. This particular result demonstrates the critical importance of randomized controlled trials (RCTs) vs. a dependence on observational studies alone.
Another large RCT in Baltimore employed a “multicomponent intervention including an online tool to help refer clients to community resources, meet-and-greet sessions between community-based organization staff and health care staff, and research assistants.” This study demonstrated no significant change in health care utilization.
While it is easy to get discouraged looking at these studies’ results, modern medicine has demonstrated success only when we look honestly and carefully at the science behind our work. Most importantly, we diligently adhere to the scientific method. Many promising hypotheses are being tested in the domain of social services and particularly in how to best integrate them with health care. As health care providers are increasingly capturing SDoH information from their patients, careful attention to evidence on evolving models of intervention will be important. Health care disparities will not be resolved without consistent time, effort, and resources by everyone in the community. Health care providers can and should play a leadership role in this journey.
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