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by Ruth Wetta
Published on November 20, 2017

Ruth Wetta is a registered nurse with advanced degrees in psychology, public health and nursing administration. She has 20 years of experience in health services and health behavior research using social determinants of health. In addition to her work at Cerner, she holds an appointment as an adjunct associate professor at the University of Kansas School of Nursing.

Social determinants of health, defined as the circumstances in which people live and work, have a strong effect on an individual's health outcomes. Factors like safe housing and local food markets have more often been the concern of public health officials and health care professionals. Although this data is incredibly useful, it has not often been used for diagnosis and treatment choices. Research has documented that individuals residing within the most disadvantaged U.S. neighborhoods are at a higher risk for hospital readmission than those living in better-positioned neighborhoods.

Due to the emphasis on caring relationships within the nursing profession, nurses may be best equipped to lead in the reduction of health disparities. Nursing education is unique in its dual focus on individual care, as well as population health and community nursing. Nurses are trained to consider the individual, family and community in evaluating clinical interventions by advocating for patients, providing education and supporting patients in their ability to self-manage their health.

One of nursing’s key roles is to plan, operationalize and evaluate the impact of the plan of care. It makes sense, then, that nursing should play a central role in understanding social determinants of health at the individual, community and population level. Through their interaction and advocacy for patients, nurses contribute to patient outcomes and population health management results.

Standardized measures for screening and surveillance of social determinants

A recent study revealed that patients care about privacy but are more concerned about being able to access and use their health information themselves. The Healthcare Information Management Systems Society is working to promote patient engagement strategies that use eHealth tools and resources to support patients in their own e-community and approach patients as partners in their care.

The American Academy of Nursing has called for the adoption of common assessment standards for social determinants of health, which will empower organizations to use patient information as a foundation for developing a treatment plan that is individualized for each patient across the continuum of care.

The use of standard measures plays two key roles: First, it provides a mechanism to efficiently recognize circumstances that may modify conditions and treatment plans. Second, it makes the information usable by various systems and health care providers for various purposes.

A number groups, including the Centers for Medicare and Medicaid Services and Healthy People 2020, have identified potential standardized measures. The Institute of Medicine has recommended 12 measurement domains of social determinants that have a potential to be used for improved patient care and population health management, and that can be consistently collected and shared. Those domains include health behaviors (alcohol use, tobacco use and exposure, physical activity), social factors (intimate partner violence, social connections and social isolation, stress, depression) and socio-demographics (census tract-median income, education, financial resource strain, race and ethnicity).

Data concerning social determinants can be collected in a variety of ways:

  • In person, by the care team during patient visits
  • Via telehealth applications
  • Through patient portals
  • From survey emails or phone calls

Standardized data metrics can leverage the predictive and explanatory power of social determinants’ impact on health outcomes at the individual, group and population level.

Understanding the influence of social determinants on populations

To excel in population health management, an organization must understand how individual characteristics and contextual factors, external to the care delivery process, impact a population’s health. Nursing serves a central role in population health management, thanks to the various patient touch points during a clinical encounter within a community, ambulatory or inpatient setting.

Consider an individual who is obese, suffers from hypertension and has a prescription for an antihypertensive medication, but doesn’t take their medication. Is this due to inability to purchase medication? Does the patient not understand the long-term effects of hypertension on their health? Does the patient have transportation barriers around picking up their prescription? These examples are linked to different health determinants. Individual characteristics may necessitate different health interventions or resources. Moreover, the interaction of the characteristics may drive how an intervention is applied.

While health care professionals cannot change a patient’s nonmodifiable determinants — like age, gender, ethnicity or race — they should still recognize how these factors can influence health and use this knowledge in care planning, delivery and evaluation. Modifiable determinants, such as health literacy, transportation barriers and self-care deficits, are certainly within the sphere of nursing practice and should be addressed through patient education and access to community resources. Additionally, nurses are well-positioned to support patients in developing confidence for self-care practices.

Empowering nurses to be advocates for community-integrated health

Linking people in need to available community resources is an important aspect of addressing the effects of social determinants.

Boston Children’s Hospital’s Community Asthma Initiative is one example of a replicable model of a population-based intervention for social determinants that extends beyond the clinical setting.

Boston Children’s launched its program after identifying that African-American and Latino children were being admitted due to asthma at three to five times the rate of Caucasian children. The program is an enhanced model of care in which nurses and community health workers provide community-based asthma care management, education and home visits. It has demonstrated consistent and significant results, with emergency visits decreasing by 58 percent and admissions decreasing by 80 percent.

Health care delivery is evolving and will continue to evolve. It’s no surprise, then, that the nurse’s role will evolve from more traditional bedside or office nursing to community outreach via phone, home visits, interdisciplinary collaboration or involvement in community collaboratives, all with the goal of improving a community’s health.

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. Learn more about our population health management solutions.

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