Environmental and social factors impact a person's health - that's something we are all starting to agree on. If I don't have to worry about where my next meal is coming from, it follows that I have more time and energy to focus on nutrition. If I have a car and have health insurance, I am more likely to see a doctor regularly to maintain my good health status.
But what about the people who don't have access to nutritious food, reliable transportation, safe housing or health insurance? Those populations are at a higher risk for health issues - and not by a small margin. Socioeconomic and environmental factors determine 50 percent of a person's health outcomes; clinical intervention impacts only 20 percent.
At almost every health care organization, there are groups of clinicians and social workers passionate about using social determinants to influence population health outcomes. That's because using social determinants - that is, the conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes - is about preventing people from getting sick and optimizing positive outcomes when they are sick.
How can social determinants impact the health of a population?
When we talk about population health outcomes, what we're usually talking about is an entity being responsible for the health of a population, which is defined either geographically or conditionally or by some other parameter. As the health care industry moves from fee-for-service to value-based care, health systems are responsible for outcomes whether their population comes to their health facilities or not. Many of the more forward-looking organizations are attempting to increase their involvement with social influences inside the geographical area they may primarily operate.
In this design, when a health care organization desires to influence the geographic region and the health outcomes of the people living in that region, their incentives shift from focusing on secondary and tertiary prevention to primary prevention.
Let's take a deeper look at those levels of preventive health care:
- Primary prevention is designed to prevent the disease from ever happening or to prevent the individual from ever getting sick. Immunization against disease and education about health and safety are examples of primary prevention.
- Secondary prevention comes after a disease or illness has presented and aims to prevent that from developing further. Health screenings and regular exams are examples of secondary prevention.
- Tertiary prevention occurs when there is a clinical intervention to help an individual manage a chronic condition or a permanent disease. Rehabilitation programs and disease management programs are examples of tertiary prevention.
Today, in a fee-for-service model, health systems are mainly paid for secondary and tertiary prevention. They're not given reimbursement for preventing an individual from coming into the hospital in the first place. Typically, it's health care officials at the state and local level that are involved with primary prevention. Health care organizations and clinicians care about it, too, but because the fee-for-service model doesn't necessarily reimburse them for primary prevention, secondary and tertiary prevention initiatives get prioritized first.
As the health care industry moves toward value-based care, the incentives for health care organizations will also change. It means that hospital and health system leaders must change the thought pattern that has dominated the industry for decades. Now, hospital stays and medical interventions shift from being revenue-generating activities for the system to being expense-generating activities that hurt their bottom line. Instead of driving referral volume to hospitals to fill beds and perform procedures, fee-for-value organizations will want to reduce hospital utilization and find ways to keep patients healthy at home. They're looking at the people who use their services and are asking themselves, "How do I treat them in the most appropriate care setting?" The ability to optimize treatment within the right venue saves costs.
How can clinicians use social determinants to improve patient outcomes?
Like anything, there are both good and bad ways to use social determinants. If we're taking a group statistic about a population and applying that to an individual, we're at risk of drawing inappropriate conclusions. It would be irresponsible, for example, to assume that all people who live in a certain ZIP code are food insecure and should be given a recommendation to apply for Supplemental Nutrition Assistance Program (SNAP) benefits. If a patient from that ZIP code comes in and we recommend SNAP when they are not eligible, they're going to waste a lot of time or even be insulted. Screening and data collection may need to occur at the individual level. This lets us see individually what health issues and social determinants are relevant to that person, and we can base our recommendations around individual data in addition to group data.
Let's say, for example, two patients come in, and in as unbiased a fashion as possible, we look at them and diagnose both patients with congestive heart failure. If we note that Patient A is married with kids, has good family support and community support and is financially secure, then the likelihood of them complying with the treatment regimen - the medication, the regular visits, the potential procedures - is higher. If we know that Patient B is homeless, doesn't have reliable transportation to the clinic or is on food stamps, we know there is a higher risk of them not adhering to the treatment plan.
With social determinants, we can tailor how we would handle care for each of these patients. Their original treatment plans might be identical; they might be getting the same medications and procedures, but Patient B needs some additional help or intervention to increase compliance with the regimen. Providing this extra help matters to a value-based organization. If either Patient A or Patient B gets sicker, the organization's performance on population health outcomes goes down and their bottom line will suffer, presumably more so than the cost of that little extra help.
In a complete "fee-for-value" world, we would ideally apply social determinants of health throughout the clinician workflow. If a patient comes in with congestive heart failure and their medical record indicates they also have diabetes and are at a high risk for food insecurity, we can direct them to tools and services to help manage that food insecurity. In that case, we're managing problems related to health, not just disease. We're expanding what we're doing for the patient and helping them stay healthy.
What does a "care team approach" mean for patient outcomes?
Physicians can't be solely responsible for using social determinants to drive better patient outcomes. Having a physician spend their time matching a patient to the right social service provider is not a good use of that resource; their time should be maximized toward diagnosis and treatment.
The commitment to prevent disease and positively impact patient outcomes has to be shared among the care team. For hospitals and other health care systems, that means bringing in more people with varying areas of expertise. Every health care organization today is thinking about the care team approach, but when we are using and acting on social determinants, we're asking the organization to execute on public health initiatives that they haven't traditionally considered - and that changes who's on the care team. In population health management, the definition is expanding to not only include the physician but also care managers, social workers, family members and even medical legal aids who can work on behalf of patients that need some assistance.
Health care is a team effort - it always has been. The idea of social determinants is also not new - public health organizations have been thinking about this for a long time. What's exciting about the evolution we are going through within our country's health care industry is that the incentives are finally catching up. The "team" dedicated to keeping our population healthy is getting larger, and the innovative thinking in health care is getting stronger.
At Cerner, we're focused on connecting traditional venues, the health continuum and advanced information about a person's lifestyle to empower individuals in their health and care. Learn more about our population health management solutions.