Social Determinants of Health

Social determinants of health (SDOH) are valuable considerations for all care providers. In Chronic Care Management (CCM), these factors can be even more valuable for creating effective care plans and improving health outcomes. Learn more about the types of social determinants of health and how you can engage your patients more effectively with CCM for better care.

What Is a Social Determinant of Health?

A social determinant of health is an environmental or economic factor that influences a person’s well-being. These determinants are not conditions or illnesses a doctor can prescribe medication or treatment for — they are created by the life around us and the circumstances we exist within.

Everyone is affected by social determinants of health. According to a study by the Office of Health Policy under the ASPE, SDOH can influence up to 50% of county-level variation in health outcomes. These factors may place a person in better standing with their health, but they can also make positive health outcomes more challenging. For care providers, understanding these social determinants is valuable for informing care.

What Are the 5 Determinants of Health?

A comprehensive list of social determinants of health could be pages long, but all determinants generally fall under five different categories. Looking at these categories can help us understand how various social factors affect how we care for ourselves. Social determinants of health have also helped us understand where disparities exist across communities. 

Economic Stability

Economic stability relates to a person’s class position and their ability to meet their basic needs with their income. In 2021, 37.9 million Americans fell below the poverty line. Those living in poverty may face housing instability and food insecurity, both of which have powerful influences on a person’s health. 

For example, housing instability may involve moving from shelter to shelter when overcrowding is an issue. To save money, large families may also try to live in small living quarters. Living in environments with too many people can lead to the transfer of various diseases. Lower incomes may also involve substandard housing with higher health and safety risks, like mold, poor HVAC systems and pests. 

Many people living in poverty face the difficult decision of choosing which basic needs to pay for each month. If housing consumes the bulk of a person’s income, they might find themselves going hungry each week. Even people who have the money to pay for food may lack the income to meet their nutritional needs, which can manifest as various health issues.

Families who are faced with food insecurity often have to prioritize the most caloric value for the lowest cost. Since healthy foods like fruits and vegetables come at higher costs for lower sustenance, they’re often overlooked. Many people living in poverty turn to fast food for the low costs and high-calorie values, which can also affect health outcomes.

The key to economic stability may seem simple — find a good job and stay there. However, many other factors can impact a person’s ability to maintain steady employment. Different conditions, disabilities and chronic illnesses may make it hard to work. In this way, health influences social determinants as much as social determinants influence health.

Additionally, awareness and access to higher-paying jobs are not available to everyone. Other social determinants of health often play a role in a person’s ability to make enough income and take care of themselves and their families. 

Education Access and Quality

When a person grows up with access to quality education, they have the foundation to explore higher education opportunities and find higher paying jobs with stable income. Access to education impacts economic stability and the health outcomes that relate to a stable income.

Additionally, quality education provides the insight children need to form into functional adults. Traits like conscientiousness, a sense of personal control, time management and the ability to form social relationships start early on in education. These skills are critical to thriving as an independent adult, and they may even influence an individual’s sense of agency when it comes to caring for their personal health.

Accessibility to a quality education begins with the family and their social determinants of health. A child who grows up in a low-income area is more likely to end up in an underfunded public school. Bruce D. Baker compiled a report for the Learning Policy Institute about the effects of school funding on student success, and discovered that high school graduation rates increased by 7% when per-pupil spending increased by 10% across all grades. 

This statistic points to the correlation between quality education and a healthier future. According to the Bureau of Labor Statistics, those with less than a high school diploma experience an 8.3% unemployment rate and make nearly $200 less per week than high school graduates. 

Underfunded education can be an influential factor in a child dropping out of school since they often lack the support they need to succeed. Other factors might include living with disabilities, frequent social discrimination and unstable home lives that involve disruption to school attendance. 

When a child does not complete high school, this can reduce their chances of attending college later in life and may lead to reduced exposure to career opportunities. Quality education informs young people about the types of careers that exist and drives aspirations for future jobs. Without this nurturing early in life, individuals may find themselves with limited career options and no resources to change their lifestyles.

Healthcare Access and Quality

Access to healthcare — particularly quality healthcare — plays a critical role in an individual’s health. Quality healthcare should detect and treat illnesses and conditions while providing preventive services to maintain health and wellness. However, barriers like shortages of care providers and inadequate or nonexistent insurance coverage may prevent individuals from getting the care they need.

According to the U.S. Census, 7.9% of full-time year-round workers had public health insurance in 2021. Employees who worked less than full-time and year-round came to 22.6%. While these numbers both increased from 2020, it does not speak to the level of coverage and whether the insurance supports regular wellness checks. 

Without adequate health coverage, individuals are less likely to see a primary care provider. These professionals can be family physicians, pediatricians, internists or other non-physician providers. Primary care providers are most likely the first to catch major illnesses and conditions before they lead to major declines in health.

Challenges in healthcare access change based on location as well. There is a stark difference in healthcare providers in rural areas compared to urban ones. The patient-to-primary care physician ratio in rural locations is 39.8 physicians per 100,000 people, while the ratio in urban areas is 53.3 physicians to every 100,000. 

There are several factors that contribute to these physician shortages among rural populations, and many of them relate to other social determinants of health. For one, most physicians end up practicing where they learn. Many medical schools are in urban centers and have connections to training opportunities with facilities in the area. Physicians learn in these locations and stay there since many rural areas lack quality education for medical students.

Secondly, rural populations are often older and poorer, which often leads to worse health. This factor leads many physicians to earn reimbursements through Medicare and Medicaid that pay less than private insurance. Additionally, physicians’ earnings are affected by health outcomes in value-based care models — sicker patients equate to less pay. 

Social determinants working against the health of a population can reduce that population’s accessibility to healthcare, creating a loop of unfavorable social determinants affecting health outcomes. 

Neighborhood and Built Environment

The environments that people live in influence their health in more ways than just access to schools and physicians. Neighborhoods provide the resources that people need in their everyday lives, from grocery stores to social spaces. When a neighborhood lacks these resources, the residents feel the effects.

While lack of access to healthy foods can be related to income, it also correlates to the type of food stores in an area. Some neighborhoods can be what’s referred to as a food desert — an area lacking in good-quality fresh foods. According to the Association of American Medical Colleges and the United States Department of Agriculture (USDA), 23.5 million people live in food deserts. 

An area becomes a food desert when a supermarket is more than 1 mile away in an urban area or 10 miles away in a rural area. Pair this distance with a lack of transportation or inability to afford gas, and getting to fresh food becomes a massive hurdle. Alternatively, gentrified neighborhoods may only feature high-end grocery stores that lower-income residents can’t afford to shop at.

Crime and violence can be other major issues that impact the health of an individual. A person may experience violence personally, witness it in their area or hear about it from neighbors. Direct violence may lead to severe injuries. If healthcare accessibility is low, these injuries may go untreated. Repeated exposure to crime and violence can also have detrimental effects on mental health, which in turn can manifest as physical health conditions.

Environmental conditions in an area also play a role in health outcomes. Contaminated water, polluted air and extreme heat are all factors that can lead to negative health effects. 

Social and Community Context

Regardless of the neighborhood or circumstances a person grows up in, they have the opportunity to build a positive community. Social and community context refers to friends, family, coworkers and other social aspects. This context can also refer to religious organizations or clubs. 

A community provides support when other factors are harder to control, like economic status or the quality of a neighborhood. These social contexts also offer a sense of belonging. Studies on the connection between community and self-rated health show that those living in weaker communities often have poorer mental and physical health. Often times, elderly populations struggle with social and community involvement, leading them to loneliness.

An established community can make a significant difference in a person’s brain and body, but it also influences behaviors. For example, an individual who spends time with people who drink or smoke may also adopt the same habits. While this community can help build a sense of belonging — a critical experience for humans — it may still have a negative impact on health. 

Is There a Correlation Between Chronic Disease and Social Determinants?

Chronic diseases typically result from years of poor lifestyle choices and social determinants like living with a lower income or lacking access to healthcare. Chronic diseases develop when small health issues or unhealthy habits go unchecked.

Some chronic diseases, like certain cancers, can develop without any clear cause, but many other chronic conditions are direct results of unhealthy choices and circumstances. Common chronic conditions include:

• Heart disease: Poor diet and lack of physical activity can lead to heart disease and even stroke. When a person lacks the income to pay for quality foods and doesn’t have access to safe physical activity in their neighborhood, preventing heart disease can be more challenging.
• Diabetes: Type II diabetes often results from being overweight or obese. Weight management issues can relate to stress from living situations and financial standing as well as poor diet and access to fresh food.
• Cancer: Lung cancer and mouth cancer are common for those who use tobacco. Smoking habits may be a result of community behaviors or accessibility in a neighborhood. 

Asking the Right Questions

When working with a patient, asking the right questions can help you understand the social determinants of health and their effect on the individual. Some patients may be aware of these social determinants and how they’re barriers to better health. Others may not be. 

The key to applying social determinants of health to a care model is building trust and cooperation with your patient, so they can be open about their experiences outside of the practice. Start with open-ended questions to begin the conversation. You might ask, “What types of foods do you eat?” This question can help you understand a person’s diet and leads to follow-up questions like, “Where do you get your food?”

Sounds easy, right? But what about when your practice is already strapped for time and resources? It can be difficult to work these conversations into the short amount of time that is spent with the patient. 

How Can Chronic Care Management Help?

Chronic Care Management programs involve many opportunities to interact with patients and deliver care with a hands-on approach. These high-touch programs lend themselves to discussions about social determinants of health and ways in which you can address them, every month, in a structured way. With a CCM program, you have the opportunity to have social-determinant conversations during regularly scheduled monthly touchpoints. 

While your CCM program may not be able to resolve all SDOH concerns, you can connect your patients with the right resources to help them meet their basic needs and improve their overall health. For instance, if your patient is living with a low income, you can work with them to find generic medications that fit their care plan and what they can afford.

At ChartSpan, our CCM solution supports you throughout a Chronic Care Management program. We help with processes like medication refills, transportation to appointments, caregiver support and much more so your CCM patients can reach their care goals. 

Our team also leads SDOH assessments in our conversations with patients to proactively respond to challenges with a patient’s condition. This ongoing communication with your CCM patients makes it possible to address SDOH and close care gaps for improved patient outcomes without adding strain to physicians’ workloads. Some of the barriers we can help with include: 

• Health Literacy
• Heat/Air Conditioning
• Medication Discounts & Delivery
• Family Support
• Safe Housing
• Nutrition & Food
• Transportation
• Financial
• Social Activity and Community
• Access & DME
• Health Equity

Request a Demo for ChartSpan

ChartSpan provides the assistance you need for a comprehensive CCM program that supports patient care plans and practice revenue. With our support staff and software, you give your CCM patients a better chance of managing their chronic conditions despite SDOH that may impact them. Request a demo or contact us to learn more today.