More than a quarter of Americans have had health risks caused by unmet social needs. Those who report having unmet social needs, such as homelessness or lack of food, are twice as likely to rate their health poorer than those whose needs were met. Social needs are generally organized into four categories: housing, transportation, food security, and relationships. However, social determinants of health (SDOH) encompass so much more than social needs.
It’s estimated that medical care accounts for only 10-20 percent of modifiable contributors to health outcomes, while social determinants of health account for the other 80-90 percent. That means addressing social determinants of health can lead to better outcomes and decreased costs. However, SDOH aren’t always recognizable to physicians at the point of care, fueling the need for collaboration across the care continuum.
What Are Social Determinants of Health?
“Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks,” according to Healthy People 2020.
Conditions include social, economic, and physical factors—while environments refer to places or settings (like workplaces, schools, churches, and neighborhoods) where conditions may occur. Social determinants of health are further broken down into social and physical.
Social determinants may include
- Education and job opportunities
- Transportation options
- Language and literacy
- Safe housing
- Access to health care services
- Exposure to crime and violence
- Poverty and other economic conditions
- Access to media and technology
Physical determinants may include
- Natural environment (green space or weather)
- Built environment (buildings or roads)
- Exposure to toxic substances or hazards
- Worksites, schools, housing, and recreational settings
- Accessible communities (especially for those with disabilities)
How Social Determinants of Health Affect Care
SDOH can affect an individual’s health dramatically. Among other things, they impact a person’s ability to understand and follow a doctor’s instructions, take time off work for appointments, and pay for treatment.
A lack of employment, low income, or poverty could mean a lack of health insurance and would make it challenging to pay for necessary medications—especially as a recent study shows that 78 percent of drugs available since 2012 have increased in cost by more than 50 percent.
Over 11 percent of adults prescribed medication in the last year said they didn’t take it as prescribed in order to save money, and that percentage jumped to more than 33 percent for those were were uninsured. Not taking a medication as prescribed may include taking less, skipping doses, or prolonging a refill. Additionally, 1 in 7 people with diabetes ration medications because of cost—a potentially fatal decision for those who depend on insulin.
Even something as simple as eating enough fruits and vegetables can be affected by SDOH. Nearly 30 million people live in areas with limited access to supermarkets, with those in rural areas traveling upwards of 20 miles to get to a full-service supermarket. A lack of reliable transportation could make it nearly impossible to get to a larger store with more access to affordable, fresh foods.
Where someone lives also affects their access to primary care and emergency services. A study of nearly 4,000 census tracts in Chicago, Los Angeles, and New York City found that black-majority neighborhoods were more likely to have less geographic access to trauma care than other races or ethnic groups.
Additionally, social determinants of health in childhood can impact a person’s health into adulthood. A recent study found an association between childhood history of both parental incarceration and juvenile justice involvement and mental health as a young adult.
Government Policies to Effect Change
Policymakers are becoming more aware of how social determinants of health affect both individual patient outcomes and healthcare spending for organizations and governments. As such, policies have been created or introduced at both the federal level and state levels.
At a federal level, H.R. 4004, or the Social Determinants Accelerator Act was introduced to Congress in 2019. This bill would establish an interagency council that would work to align resources and develop strategies to improve outcomes for vulnerable populations.
On the state level, 29 bills specifically mentioning social determinants of health or health-related social needs were introduced in 11 states as of February 2019.
In 2018, the California Senate Bill 1152 was enacted, placing a range of requirements for homeless patients on hospitals. These include providing meals and clothing, enhanced discharge plans and safe discharges, coordinating with community providers, and logging hospital encounters.
How Payers are Addressing Social Determinants of Health
A failure to screen for and address social determinants of health leads to unsustainable health care costs for all parties involved. Payers across the nation are implementing changes to better address SDOH and support members, including strategies to provide healthy meals or food and give members free rides to medical appointments.
These efforts have real impacts on outcomes for payers, providers, and patients. One payer realized an 11 percent decrease in costs. Medicaid members receiving community-based services addressing SDOH experienced an over 26 decrease in hospital admission rates.
What Hospitals, Health Systems, and Physicians Can Do
The number one thing clinicians can do is record social determinants of health whenever possible, whether that’s through ICD-10 diagnostic codes, specific EHR documentation, clinical notes, or collaborative tools like Collective Medical’s platform.
Physicians, nurse practitioners, and physician assistants working in primary care were surveyed about SDOH. With about half of the surveyed participants reporting that they referred patients to community resources, Collective’s platform enables that much-needed collaboration. With real-time insights, care team members, community-based organizations, social workers and case managers can all be notified as patients move throughout the care continuum. Real-time collaboration means information is readily available to all relevant providers and clinicians once it’s identified—enabling coordination for better overall outcomes.
In 2018, Providence Health launched the Better Outcomes [thru] Bridges, or BOB, program in its Oregon facilities. This program involves key community members to better service patients being affected by SDOH. Using Collective’s platform to host care plans and coordinate care, Providence has seen a 41 percent reduction in ED utilization by BOB patients.