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The Social Determinants of Health & How to Address Them in Your Practice

Jon-Michial Carter
Written by Jon-Michial Carter

The role of healthcare providers extends beyond medical treatment. Your patients' well-being depends on their Social Determinants of Health (SDOH), which encompasses non-medical factors that significantly impact their health outcomes.

Addressing SDOH requires a comprehensive understanding of your patients' socioeconomic and environmental considerations. This includes evaluating access to safe housing, nutritious food, reliable transportation, and education, all of which profoundly influence health outcomes.

By integrating Chronic Care Management (CCM) into your practice, you can address patients' immediate medical needs and actively tackle the root causes of health disparities rooted in SDOH. CCM is not merely a clinical strategy but a comprehensive approach that addresses the relationship between medical conditions and the broader context of patients' lives. 

This article discusses the impact of SDOH on patient health and the actionable steps you can take within your practice to address these determinants effectively. Tackling SDOH with a Chronic Care Management program will equip you to create effective care plans and improve the health outcomes of your patients.

What are the Social Determinants of Health?

Social Determinants of Health (SDOH) refer to environmental or economic factors that significantly impact an individual's well-being. Unlike medical conditions or illnesses treated with medication or therapy, SDOHs are shaped by the societal and economic conditions in which people live and operate.

The five domains of Social Determinants of Health

A comprehensive catalog of all Social Determinants of Health (SDOH) would be extensive, but almost all determinants fall into five distinct categories.

1. Economic stability

Economic stability is intricately tied to an individual's socioeconomic status and capacity to fulfill basic needs with income. Arguably, poverty is the most profound social determinant, with consequences that ripple throughout an individual's life. It magnifies the influence of other determinants, leading to poorer health outcomes and perpetuating a cycle of disadvantage. 

In 2022, approximately 37.9 million Americans lived below the poverty line. Such a circumstance often translates to housing instability and food insecurity.

The path to achieving economic stability may appear straightforward at first glance – securing and maintaining a stable, well-paying job. However, the reality is far more complex. Numerous factors impact a person's ability to sustain steady employment. Health, for instance, can be a significant factor. Disabilities and chronic illnesses can pose formidable barriers to consistent work. Many Medicare patients are also retired and living on a set income. In this regard, health and social determinants mutually influence each other to a substantial extent.

Examples of economic stability challenges

Housing instability: This prevalent issue often results in families relocating from one shelter to another due to overcrowding or attempting to cope with limited resources in cramped living quarters. These unstable living conditions can facilitate the transmission of diseases, giving rise to significant health risks.

Substandard housing conditions: Lower incomes frequently lead to substandard housing conditions marked by problems like mold, inadequate HVAC systems, and pest infestations. These living conditions compromise overall well-being and expose individuals and families to health and safety hazards.

Food insecurity and nutritional challenges: Living in poverty often forces individuals to make difficult choices, including prioritizing basic needs each month. When housing costs consume a substantial portion of income, people may face food insecurity, leading to hunger and health issues. 

Families confronting food insecurity must frequently prioritize high-calorie, cost-effective food choices over healthier alternatives like fruits and vegetables, which come at a premium. Even when there is money for food, nutritional needs may still not be met, which can result in long-term health challenges.

Employment and income barriers: Employment and income stability are foundational to securing critical resources like nutritious food, safe housing, and quality healthcare. Access to higher-paying job opportunities is only equitable for some individuals. Numerous social determinants of health, including factors such as education and discrimination, can influence a person's ability to secure sufficient income and provide for themselves and their families.

2. Education access and quality

A solid educational foundation opens doors to higher education opportunities and paves the way for more lucrative employment prospects and a stable income. Quality education also equips children with essential life skills for developing into functional and self-sufficient adults. Traits like conscientiousness, personal control, effective time management, and forming meaningful social relationships often take root during early education. These skills can even influence a person's sense of agency when managing their health.

However, accessibility to quality education often hinges on family dynamics and their relationship with Social Determinants of Health. For instance, a child growing up in a low-income area is more likely to attend an underfunded public school, which can have far-reaching consequences on their ability to generate income in the future.

This correlation between quality education and a healthier future is evident in statistics. According to the Bureau of Labor Statistics, individuals with less than a high school diploma face a 5.5% unemployment rate and earn nearly $200 less per week than high school graduates.

Examples of education access and quality 

High school dropout rates: Underfunded education systems contribute toward high school dropout rates. Students in under-resourced schools often lack the support and resources for academic success. 

Additionally, other factors such as disabilities, frequent social discrimination, or tumultuous home lives marked by disruptions to school attendance can further compound the challenges students face on their educational journey. 

Limited career opportunities: When a child does not complete high school, their chances of attending college later in life dwindle, limiting their exposure to various career opportunities. 

Quality education imparts knowledge and informs young people about diverse career options to inspire future career pursuits. Without this crucial early nurturing, individuals may have restricted career options and inadequate resources to transform their life trajectories.

Healthcare Access and Quality

3. Healthcare access and quality

Quality healthcare covers the detection and treatment of illnesses and the preventive services aimed at maintaining overall well-being. Unfortunately, barriers such as shortages of healthcare providers and inadequate or absent insurance coverage can hinder individuals from accessing the care they require. According to the U.S. Census data from 2022, 10.8% of working-age adults are uninsured. 

Individuals with limited access may encounter delays in crucial diagnoses and treatment, which can exacerbate health issues. Although Medicare patients have health insurance, lacking insurance earlier in their lives could already have contributed to long-term health problems. 

Disparities in healthcare access are highly influenced by geographic location. Rural areas face a significant shortage of healthcare providers compared to urban centers. For instance, the patient-to-primary care physician ratio in rural locations is 39.8 physicians per 100,000 people, while urban areas have a ratio of 53.3 physicians for every 100,000 individuals.

Examples of healthcare access and quality

Limited primary care access: Inadequate health coverage often reduces visits to primary care providers, such as family physicians, pediatricians, internists, or other non-physician providers. Primary care providers are crucial as they are often the first to identify significant illnesses and conditions before they lead to severe health decline.

Rural healthcare disparities: Several factors contribute to physician shortages in rural areas, many of which are intertwined with other Social Determinants of Health. Firstly, physicians tend to establish their practices in urban areas, in close proximity to medical schools and training opportunities. Rural areas, on the other hand, often lack educational institutions equipped to train medical students effectively. 

Secondly, rural populations typically comprise older and lower-income individuals, often leading to poorer overall health. This leads many physicians serving rural communities to rely on reimbursements from government programs like Medicare and Medicaid, which generally offer lower compensation than private insurance plans. Moreover, physicians' earnings can be affected by the health outcomes of their patients in value-based care models, where sicker patients may result in lower compensation. 

Both the lack of opportunities and lower compensation do little to encourage physicians to practice in rural areas. 

4. Neighborhood and physical environment

Neighborhoods provide essential resources for daily life, ranging from access to grocery stores to communal spaces. When a community lacks these fundamental resources, its residents inevitably bear the consequences.

A 2014 study found that patients living in the most disadvantaged neighborhoods faced a higher risk of rehospitalization within 30 days of discharge. This research reveals the critical role of neighborhood socioeconomic factors in health outcomes, highlighting the relevance of SDOH in understanding healthcare disparities and readmission risks.

Additionally, in some neighborhoods, residents reside in what's commonly called a "food desert" — an area characterized by a scarcity of high-quality, fresh food options. According to the Association of American Medical Colleges and the United States Department of Agriculture (USDA), approximately 23.5 million people reside in these food deserts.

When residents lack access to fresh and nutritious foods, they are more likely to rely on processed and unhealthy alternatives, which can lead to a higher prevalence of diet-related chronic diseases, such as obesity, diabetes, and cardiovascular problems. These health conditions, in turn, contribute to increased healthcare costs and poorer overall well-being within affected communities.

Examples of neighborhood and physical environment

Lack of healthy food options: An area qualifies as a food desert when the nearest supermarket is more than 1 mile away in urban settings or 10 miles away in rural areas. With factors like a lack of transportation or the inability to afford gas, accessing fresh and healthy food becomes an enormous challenge for residents. Conversely, gentrified neighborhoods may exclusively feature high-end grocery stores, making them financially inaccessible to lower-income residents.

Crime and violence: An individual may personally experience violence, witness it within their community, or hear about it from neighbors. Direct exposure to violence can lead to severe injuries, and if healthcare accessibility is limited, these injuries may go untreated. Additionally, repeated exposure to crime and violence can have detrimental effects on mental health, which, in turn, can manifest as physical health conditions.

Environmental health concerns: Contaminated water sources, polluted air quality, and extreme heat can lead to adverse health effects, highlighting the relationship between the physical environment and public health.

Lack of transportation: Reliable transportation is crucial in accessing healthcare facilities, nutritious food, and education. Limited transportation options can hinder individuals' ability to make appointments, pick up prescriptions, or buy basic necessities.

Social and Community Context

5. Social and community context

Social and community context encompasses relationships with friends, family and coworkers and other social aspects, including participation in religious organizations or clubs. Regardless of their upbringing or surroundings, individuals have the chance to cultivate a positive community. 

A community provides support when other factors, like economic status or neighborhood quality, are more challenging to control. These social contexts also offer a sense of belonging. Research examining the link between community and self-rated health reveals that individuals residing in less cohesive communities often experience poorer mental and physical health. Additionally, older populations frequently grapple with issues related to social and community engagement, which can lead to feelings of isolation and loneliness.

The impact of an established community extends beyond mental and physical well-being to include behaviors. For instance, individuals who spend time with peers engaged in habits like drinking or smoking may be more inclined to adopt similar behaviors. While such communities contribute to a sense of belonging, a vital human experience, they can also adversely affect health.

Residing in neighborhoods characterized by high collective efficacy, where residents believe in their ability to address community challenges collectively, has been found to correlate with improved physical health. Participating in local voluntary organizations has shown associations with a healthier BMI and enhanced emotional well-being. Additionally, strong social cohesion, marked by tight-knit social relationships and a sense of unity, has been linked to reduced depressive symptoms and the adoption of favorable health-related behaviors. 

Examples of social and community context

Community resources: Access to vital community resources like food banks, mental health support groups, and low-cost healthcare clinics can directly and indirectly impact health outcomes. Communities that offer comprehensive and accessible resources often see improved overall health outcomes among their residents.

Religious and cultural affiliations: Engaging actively in religious or cultural communities provides individuals with strong social networks, emotional well-being, and a sense of purpose. These factors are crucial in enhancing mental health and resilience for coping with health challenges, ultimately leading to better health outcomes.

Community engagement: Communities that actively engage residents in decision-making processes and civic activities tend to have healthier populations. Actively participating in healthcare-related endeavors and a broad spectrum of community activities not only fosters positive health outcomes but also empowers residents to take a central role in influencing the health of their community.

Why are the Social Determinants of Health important?

Poor Social Determinants of Health contribute to disparities in access to healthcare, education, and living conditions, resulting in unequal health outcomes among different population groups. These disparities can lead to increased healthcare costs and reduced economic productivity, making the consideration of SDOH crucial for public health and the economy.

SDOHs are also a direct cause of infectious diseases. Poor housing conditions, lack of access to clean water, overcrowding, and limited healthcare access in underserved communities can create ideal conditions for the spread of infectious diseases. These factors make individuals more susceptible to infections and hinder early detection and treatment, leading to the rapid transmission of diseases within communities.

Furthermore, SDOHs influence the development and exacerbation of chronic diseases. Factors like limited access to nutritious food and economic instability contribute to unhealthy lifestyle choices, such as poor diet and lack of physical activity, which are major risk factors for chronic conditions like diabetes, heart disease, and obesity. Inadequate access to healthcare services for early detection and management of chronic diseases also exacerbates these health disparities.

Addressing SDOH encourages preventive care, which can reduce the burden of preventable diseases and enhance healthcare system efficiency. By improving access to primary care services, health education, and resources for healthy living, SDOH initiatives enable individuals to adopt healthier behaviors and lifestyles. 

This proactive approach leads to early detection and intervention and significantly reduces emergency room visits for preventable conditions. Consequently, healthcare resources are utilized more effectively, with an emphasis on preventive measures and the management of chronic diseases.

How Social Determinants of Health affect chronic disease

Chronic diseases typically develop over time as a result of a combination of lifestyle choices and social determinants. These determinants can include factors such as low income or limited access to healthcare. In many cases, chronic conditions originate from the unchecked progression of minor health issues or unhealthy habits.

While certain chronic diseases, like some cancers, may arise without a clear cause, many others are directly linked to adverse circumstances. For example, heart disease and stroke often result from a poor diet and insufficient physical activity. Individuals who lack the financial means to afford nutritious foods or access safe places for exercise in their neighborhoods may face more significant challenges in preventing these conditions.

Similarly, Type II diabetes is often associated with being overweight or obese, which can be influenced by stress related to living conditions, financial constraints, and limited access to fresh, healthy food. Additionally, certain cancers, such as lung and mouth cancers, are more common among tobacco users, and smoking habits may be shaped by community behaviors or accessibility factors within a neighborhood.

These examples demonstrate the correlation between individual choices, socioeconomic factors, and environmental influences in the development of chronic diseases, which makes addressing Social Determinants of Health essential to preventing and managing these conditions effectively.

Addressing Social Determinants of Health in your medical practice

Building patient trust is crucial for incorporating SDOH into a care model. During an office visit, create an environment where patients feel comfortable sharing their experiences beyond the clinical setting so you can determine how SDOH may contribute to their illness. When working with patients, taking a few extra minutes to ask questions related to their lifestyle, environment, and emotional well-being is essential for understanding the impact of Social Determinants of Health (SDOH) on individuals. 

Some patients may already recognize these SDOHs and how they act as barriers to better health, while others may need to be made aware. Begin with open-ended questions to initiate the conversation, such as, "What types of foods do you eat?" This question can provide insight into their diet and lead to follow-up inquiries like, "Where do you source your food?"

However, addressing SDOH can be challenging, especially when your practice is constrained by limited time and resources. Incorporating these discussions within the brief windows of patient interaction takes time and effort that you may not always have.

For this reason, outsourcing Chronic Care Management (CCM) for eligible Medicare patients can benefit you. CCM programs offer numerous opportunities for meaningful patient engagement. They are well-suited for addressing SDOH as they provide structured, monthly touchpoints with patients. 

How a CCM program strengthens SDOH integration

Chronic Care Management (CCM) programs are critical in addressing Social Determinants of Health (SDOH) by seamlessly connecting chronically ill patients with essential resources. These programs offer a structured framework that not only bridges the gap between limited time and comprehensive care but also delivers a multitude of benefits:

Assessments and screening

CCM programs conduct comprehensive patient screenings that delve into various SDOH aspects, including housing stability, food security, and transportation access. These assessments provide you with valuable insights, allowing you to pinpoint patients facing specific SDOH challenges.

Individualized care plans

CCM requires personalized care plans to be created and provided for each patient based on risks identified in screenings. These plans extend beyond addressing medical conditions and incorporate the social and economic factors influencing health, guiding patients toward improved overall well-being.

Community connections

CCM care teams can assist patients in connecting with community resources and support services that address SDOH. This may involve referrals to social workers, community organizations, housing assistance programs, or transportation services to help patients overcome barriers. For example, if patients face food insecurity, a CCM care team can connect them with local food banks or social services to provide resources.

Patient education and support

CCM programs educate patients on managing their chronic conditions so they can become active participants in their care journey. CCM encourages ongoing and proactive communication with patients through monthly touchpoints with care team members and 24/7 access to a nurse line. This regular interaction allows you to discuss and address SDOH-related concerns and better understand patients' needs and preferences.

Medication management

SDOH factors can impact a patient's ability to adhere to medication regimens. CCM programs assist patients with prescription refills and monitor medication adherence. If a patient faces financial challenges, providers can collaborate to explore cost-effective medication options that align with their care plan and budget.

How to address the Social Determinants of Health with ChartSpan’s Chronic Care Management program

At ChartSpan, we offer a full-service Chronic Care Management program to help you address the Social Determinants of Health in your patient population. We offer assistance with various processes, including medication refills, appointment transportation, and caregiver support to ensure your CCM patients can reach their care goals.

Our care team leads SDOH assessments in our conversations with patients to proactively respond to challenges with a patient’s condition. By maintaining ongoing communication with your CCM patients, we can identify and react to SDOH-related difficulties that may affect a patient's condition. This approach allows us to address SDOH factors and bridge care gaps, ultimately leading to improved patient outcomes without adding extra burden to your practice workload.

When SDOH risks are identified, our team can connect your patients with transportation, housing resources, food banks, exercise classes, religious groups, and volunteering opportunities. This proactive approach addresses the root causes of health disparities, reduces barriers to accessing essential resources, and empowers your patients to lead healthier lives.

With ChartSpan's supportive care team, you can implement a comprehensive CCM program that supports your patients' care plans and enhances your practice's revenue. By leveraging our resources, you empower your CCM patients to better manage their chronic conditions, even in the face of SDOH challenges that may impact them. 

Contact us today to discover more about our CCM solution or receive a demo.

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