Only 20% of health outcomes are influenced by clinical care.
That’s right. Only 20%.
It turns out that the other 80% of health outcomes are influenced by social determinants of health (SDOH).
Recent years have exposed and widened many existing health disparities, which are also known as health-related social needs (HRSNs). These factors include childcare, transportation, and social support.
Forty-five percent of U.S. consumers experience at least one HRSN on a regular basis. The majority of this group (29% of all U.S. consumers) has three or more HRSNs.
What are social determinants of health, and what can you do to address them in your patient population? Here’s a look at what you can do and how adopting the right healthcare tools is essential to your success.
SDOH are “the conditions under which people are born, grow, live, work, and age,” according to the American Academy of Family Physicians (AAFP). These conditions can include risk factors such as food scarcity, secondhand smoke inhalation and unsafe neighborhood conditions.
Unfortunately, no amount of clinical care can take away these risk factors, and yet these risk factors are incredibly common. In fact, 60% of consumers reported that they were adversely affected by at least one SDOH in a Leavitt Partners 2019 survey.
And the COVID-19 pandemic didn’t help: it actually exacerbated the connection between inequality and health outcomes. Although only 20% of health outcomes are influenced by clinical care, physicians can still play a huge role in SDOH for their patients. Organizations such as the AAFP, CDC and World Health Organization have even made great strides to encourage or assist physicians in their SDOH efforts. The American Heart Association has an SDOH assessment tool to help with routine care for patients with heart failure.
SDOH can be difficult to wrap your head around, but the Department of Health and Human Services breaks SDOH into 5 categories.
Economic stability refers to factors such as income, cost of living, food security and housing stability, etc. In the United States, one in ten people live in poverty, often having to choose between primary needs like rent or food and medication. They literally can’t afford to maintain their health.
Plus, research shows that food insecurity is one of the most critical health and nutrition issues, especially in children. Food insecurity can lead to many negative health outcomes such as anemia, asthma, aggression, anxiety and poorer oral health.
Furthermore, “food insecurity is a more powerful predictor of pain and prescription opioids use than income,” according to population health research.
Medical debt also creates serious barriers to care. Twenty percent of Americans owe medical debt, which can lead them to delay preventive visits, skip medications, or postpone recommended procedures. Those decisions can lead to more expensive treatment later and diminish patients’ quality of life.
Education access and quality refers to factors such as literacy, early childhood education, and educational attainment.
We’ve heard it before: it’s harder to get a good job without a high school diploma, at least. But it’s true. Without a high school diploma, it’s substantially more difficult to earn a well-paying salary and that makes it harder to afford food, transportation, housing, and healthcare.
In fact, research shows that “high school dropouts were at increased odds of reporting a serious chronic health condition (e.g., asthma, diabetes, heart disease, high blood pressure) even after accounting for the influence of age, income, gender, marital status and any alcohol or drug addiction.”
A patient’s education level also influences their employment opportunities and lifetime earnings. People with higher education typically earn more and receive employer-sponsored health insurance more often. They also encounter fewer financial barriers to healthcare.
Better health literacy helps patients understand prescriptions, follow treatment instructions, and manage chronic conditions.
Health care access and quality refer to factors such as access to health care, health insurance coverage, health literacy and primary care access.
According to the Commonwealth Fund’s 2020 Biennial Health Insurance Survey, 35% of all adults are “at least one cost-related problem getting needed health care in the past year including not filling a prescription; skipping a recommended test, treatment or follow-up visit; not going to a doctor when sick; or not getting needed specialist care.”
Other research shows that “low health literacy is associated with poorer health outcomes and poorer use of health care services.”
Cost remains one of the biggest barriers to healthcare access. Roughly one out of every three Americans delays or skips needed medical care because of financial concerns. These challenges are exacerbated by a lack of specialists, limited insurance coverage, and high deductibles.
When patients cannot access timely care, providers often see more advanced illnesses that require more complex treatment.
Neighborhood and built environment include factors such as access to transportation, air and water quality, housing quality and neighborhood safety, along with other factors like secondhand smoke exposure and noise pollution.
Have you ever thought that where you live could be what is making you sick?
Though there are multiple reasons a neighborhood could affect health, something to consider is indoor air quality. Indoor air pollution can negatively affect health for everyone, but especially those with respiratory or cardiac concerns.
Another issue, lack of transportation, can also negatively affect health, as it can make people late or miss doctor appointments, delaying or preventing care.
Many communities are food deserts, meaning they have limited access to healthy food. Food deserts reduce access to nutritious meals, while environmental pollution varies between ZIP codes.
These communities tend to lack reliable public transportation and safe parks as well. Patients without dependable transportation are more likely to miss appointments or delay follow-up care.
Patients typically experience several overlapping HRSNs. These overlapping barriers compound, decreasing the likelihood of positive outcomes for patients with chronic health conditions.
Social and community context refers to factors such as civic participation, having a supportive community, incarceration, workplace conditions and discrimination.
As it turns out, mental health (e.g., psychological stressors such as loneliness or racism) can have a huge effect on physical health.
USC and UCLA research found that racist experiences increase inflammation and raise the likelihood of chronic illness in Black patients. As it turns out, Black people are more likely to die from cancer and heart disease than white people, and Black neighborhoods generally have health care provider shortages.
Psychological stress affects much more than emotional well-being. Patients who suffer chronic stress tend to experience increased inflammation, high blood pressure, and exacerbations of conditions such as diabetes and heart disease.
When patients experience discrimination, social isolation, and unstable employment, they are less likely to adhere to treatment protocols.
Offering strong community support can help individuals in underserved areas overcome these barriers. The goal is to form trusted healthcare relationships while offering culturally responsive care.
The two most important things a physician practice can do when it comes to SDOH is to 1) screen patients for risk factors and 2) offer resources such as contacts or locations that can help them.
Remember how 60% of consumers reported that they were adversely affected by at least one SDOH in a Leavitt Partners 2019 survey? It turns out that these patients weren’t often screened for SDOH needs. For instance, only 9% of survey respondents who struggled with food insecurity said someone in their doctor’s office asked them about food access.
Successful SDOH programs begin with consistent screening. Many practices add standardized questions directly into the electronic medical record. Alternatively, you can include screening forms during appointment scheduling.
Every team member should understand their role in your screening process so that they can support patients in need.
You should also account for language differences and transportation limitations when making referrals. Following up after the referral helps you measure success and identify patients who need additional support.
Here’s a step-by-step breakdown of how to support your patient population using these strategies:
Addressing social determinants of health requires a cultural shift within your practice. Every staff member should communicate with patients with empathy and avoid language that makes them feel shame. Patients often hesitate to discuss their financial struggles, food insecurity, or housing instability.
Patient navigators play an important role in helping patients understand what resources are available to them. If you don’t have dedicated navigators, assign these responsibilities to existing staff members and partner with local organizations.
Here are some strategies for screening for SDOH risk factors:
Practices can also choose from several validated screening tools. The PRAPARE assessment works well for community health centers and practices that serve vulnerable populations.
If you run a smaller physician practice, the AAFP screening template is shorter and easier to integrate into your workflows. Select the right tool for your patient population and staffing levels.
Screening is the first step in identifying patients who are facing SDOH. An effective SDOH program creates a clear referral process that identifies patient needs, connects them with appropriate community support, and follows up to confirm they received assistance.
Use your relationship with patients to facilitate warm handoffs, which improve participation rates.
Social determinants of health, such as financial barriers and a lack of transportation, lead to:
When you address SDOH, you can promote better revenue cycle performance. Combine your SDOH screening with healthcare revenue cycle management solutions that improve financial visibility across the patient journey. Improving patient access helps reduce payment delays while boosting patient satisfaction.
Now that you’ve fully explored the question, “What are social determinants of health?” it’s time to move the needle in your community. To do that, you need a clear view of the revenue cycle and powerful tools that make your organization more efficient.
Rivet Health helps organizations improve financial transparency through accurate patient estimates, revenue insights, and modern revenue cycle tools that support both patients and providers.
For more information about Rivet's modern product suite, schedule a Rivet demo. Download our e-book to learn more about social determinants of health.
Many patients won’t tell you about their social determinants of health or the challenges they face unless you directly ask. Implementing a standardized screening during registration or pre-visit check-in helps you identify these concerns sooner.
Many smaller practices assign these responsibilities to existing staff members. You can also look for community partners that provide support for your patients.
When you educate patients about their financial responsibility and connect them with help to overcome barriers, they will complete the course of care with greater consistency. You can also improve collections and strengthen the overall performance of your revenue cycle.
Yes. Start with a short screening questionnaire and implement a mechanism for collecting and analyzing that data. Gradually expand your program to align with the needs of your patient population.
Social barriers can contribute to missed appointments and delayed treatment, both of which can affect insurance claims. Strong patient communication and coordinated workflows help reduce avoidable reimbursement issues.