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Social Determinants of HealthFAQ

Q: What are social determinants of health (SDOH)?

A: Although people might see their doctor only once a year, they are exposed to the health and safety conditions in their homes, their neighborhoods, their schools, and their communities every single day. Overlapping and complex social factors—poverty, education, discrimination, literacy, housing, exposure to violence, access to healthy food, transportation, access to healthcare, and many others—play an integral role in an individual’s health and health of populations. These factors, known as social determinants of health, are the conditions under which people are born, grow, live, work and age.

Q: Why are SDOH important?

A: Put simply, social determinants of health are critically important because they have a major impact on people’s lives. Socioeconomic status, education, housing, and other factors indelibly shape individuals’ health-related behaviors, their health outcomes, and their mortality. Or, as the Robert Wood Johnson Foundation states, “Zipcode is a much more powerful predictor of health than genetic code.”1 For example, poor patients with inadequate housing and unreliable access to transportation are far more likely to face difficulties managing chronic illness or to be readmitted following a hospitalization than patients in higher income brackets. Social determinants of health are key drivers of healthcare disparities—preventable inequities in access, availability and quality of healthcare for different groups of the population, especially those living in poverty and racial and ethnic minorities. As a growing body of research reveals the scope of social determinants’ effects on health, most experts agree that addressing them is necessary to make the healthcare system truly equitable.

Q: What are some of the ways that SDOH affects patients’ health outcomes?

A) Whether it’s a child living in an unsafe area with no green space or playgrounds, an older adult with few friends or family members nearby, a family facing food insecurity and hunger, or a pregnant woman with no access to prenatal care in her community, social determinants of health affect peoples’ lives in myriad ways. These determinants can mean the difference between a long, healthy life and one plagued by chronic disease and shortened by early mortality. Research from the Robert Wood Johnson Foundation found that a population’s health is shaped 50% by social, environmental and economic factors, 20% by access to healthcare and 30% by individual behaviors, such as smoking.2 And, social and environmental factors account for roughly a fifth of premature deaths in the U.S. each year, according to research from a Kaiser Family Foundation report.3

Q) How can social determinants of health be addressed?

A) The ways to address and improve social determinants of health are as varied as the determinants themselves. One community might launch a Meals on Wheels program to reach vulnerable seniors, while a local charity might raise money for a children’s center. As awareness about the scope and impact of social determinants of health has grown in recent years, policymakers, community groups, healthcare organizations and non-profits have begun to systematically address the overlapping factors that affect the health of patient populations. For instance, many state and local public health departments are looking closely at ways to more effectively identify the root causes of health inequities, gathering data and developing targeted interventions to address the social, economic and environmental challenges faced by different patient populations. The federal government also has multiple initiatives aimed at addressing social determinants of health, including several efforts overseen by the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion. Q) What role can healthcare providers play in addressing SDOH?

A) Is a diabetes patient struggling to adhere to his medication regimen because he’s forgetful or because he can’t afford his copay? Is a child eating few fruits and vegetables because her family lives in a food desert? Will a patient with the end-stage renal disease be able to make it to dialysis appointments without a reliable car? A growing number of healthcare providers are expanding their frame of reference to better understand how social factors impact health and to address them with their patients. A 2016 editorial in the Annals of Family Medicine argued that clinicians play a key role in identifying and helping to improve social determinants of health. Primary care providers, in particular, the editorial stated, are uniquely suited to work with patients, their families, community groups, and other entities to tackle such issues as hunger, poverty, and unsafe housing.

Q) How can identifying and confronting social determinants of health lead to improved care and better outcomes?

Numerous research studies have demonstrated that non-clinical factors have a far greater impact on patients’ health than medical care and services. Addressing even a few of those factors can lead to significant health improvements and reduced mortality for vulnerable patients with multiple complex needs. Many practices, for instance, have begun hiring care managers to connect patients facing socioeconomic challenges with relevant social services and community groups. Others have introduced cultural competency training to help their staff provide more sensitive care. What’s clear is that it will be nearly impossible to meaningfully reduce health disparities without focusing on social determinants of health—and clinicians have a pivotal role to play. Q) What are some of the challenges clinicians face in working to improve social determinants of health?

In a recent editorial in the Annals of Family Medicine, the authors noted that primary care in the U.S. has a long history of looking broadly at the social challenges many patients face.5 But the fee-for-service payment structure has hindered clinicians’ efforts to address social determinants of health in a more deliberate, systematic way, the authors said. Put plainly, clinician time spent trying to help patients overcome social and environmental challenges is often not reimbursable. Fortunately, that is changing with value-based models of care that incentivize care coordination and preventive care, such as accountable care organizations and the patient-centered medical home, but prog

ress is slow. In addition, most clinicians are already overwhelmed by how much they must accomplish during short office visits, and adding one more task—especially discussing sensitive topics like poverty and violence—feels daunting. In a survey of primary care physicians, 80% said they believed unmet social needs hindered patient health but said they did not yet feel equipped to address those needs. Q) Could an automated collection of patient-reported data help address SDOH?

New technologies are making it far easier to collect social determinants of health data and use it to make care more meaningful. According to an editorial in the Annals of Family Medicine, “Technological advances have made it possible to better integrate SDH data into electronic health records, facilitate primary care teams’ efforts to address patients’ SDH, and enable teams to coordinate community service referrals and other SDH-related actions.”7 Data related to many different social, economic and environmental factors—including sensitive topics that patien

ts might be hesitant to share face-to-face, such as intimate-partner violence, access to healthy food and safe housing— can be captured automatically during the patient intake process.

End Notes 1. “Why ZIP Codes Matter: Advancing Health Equity in All Policies,” The Robert Wood Johnson Foundation’s Culture of Health Blog, Dec. 1, 2014. matter.html 2. County Health Rankings & Roadmaps, Robert Wood Johnson Foundation. http://www. 3. “Beyond He

alth Care: The Role of Social Determinants in Promoting Health and Health Equity,” Kaiser Family Foundation, Nov. 4, 2015. the-role-of-social-determinants-in-promoting-health-and-health-equity/ 4, 5, 7 “Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care Practice,” Annals of Family Medicine, March/April 2016. http:// 6 “Healthcare’s Blind Side,” Robert Wood Johnson Foundation, 2011. research/2011/12/health-care-s-blind-side.html

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