Why social determinants of health should be a top priority for hospitals

— By Theresa Green, PhD, MBA, Director, Community Health Policy and Education, Center for Community Health and Prevention, University of Rochester Medical Center

Every day, healthcare professionals work to understand health trends and disease patterns. What are the causes of illness and disease? Why are some people and communities healthier than others?

While access to care may be the first thing that comes to mind, it’s just one of many determinants of health. Ichiro Kawachi, MD, PhD, epidemiologist from the Harvard School of Public Health puts it this way: “healthcare can deal with diseases and illness. But a lack of healthcare is not the cause of illness and disease.” In fact, research has shown that nearly 80% of the factors that affect a person’s health are non-medical in nature. Authors Kaplan and Millstein estimate 0% to 17% of premature mortality is attributable to deficiencies in health care access or delivery, while behaviors, genetics, environment and social circumstance are the primary drivers of health outcomes.

The importance of SDOH

Social circumstance is of paramount importance when examining drivers of health and longevity. The World Health Organization defines SDOH as, “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”

SDOH not only have a direct positive or negative impact on health outcomes, but they also have an additive, indirect impact through behaviors, environment and genetic expression. Inequities in social determinants are often the cause of health disparities — unfair and avoidable differences in health status based often on race, gender or economic position.

Social determinants are often driven by political and structural institutions. In his book, The Political Determinants of Health, Daniel E. Dawes asserts that political forces and decisions create social drivers such as poor transportation systems, inadequate education, unsafe neighborhoods, lack of healthy food and insufficient housing, all of which impact health.

Healthcare systems and their workforces are in the business of ensuring health — the state of physical, mental and social well-being, not merely the absence of disease or infirmity. Since social determinants are the primary drivers of health, it is important for healthcare systems to consider social circumstances in patient care.

Identifying SDOH

What do negative SDOH look like? They can look like a patient with hypertension, living in a neighborhood with very little access to healthy food but an abundance of convenience stores and fast food. Maybe their town lacks parks and safe places to walk. That patient might live in the under-resourced neighborhood because they lack adequate income, or perhaps they are in a racial minority group that was once legally prohibited from moving to resource-rich neighborhoods. There are many ways one’s environment can influence health.

While healthcare organizations may have different SDOH categories, most SDOH discussions at least include poverty, discrimination and social isolation as core social drivers. Poverty and racial discrimination underly most other institutionalized socially-based determinants.

Healthcare institutions must explore implicit biases, counteract structural racism, and create an environment focused on addressing SDOH within and outside the healthcare setting. This begins with patients feeling more comfortable in healthcare spaces. They should trust their providers and feel free to share important details about their lives. Collecting self-reported demographic data on race, ethnicity, sexual orientation and gender identity allows individuals to select multiple options (not including the “other” category) to describe themselves. This is critical for identifying inequalities and disparities in health outcomes.

Poverty is a powerful SDOH. The persistent stress of poverty impacts the mental and physical health of individuals and their communities both directly, through physiological changes, and indirectly, through housing insecurity, food insecurity, increased violence, lack of safety and increased risk of engaging in unhealthy behaviors.

Examining Monroe County and the city of Rochester, New York, we can see the close connection between poverty and health outcomes, which is documented in a report created by Common Ground Health, Overloaded: The Heavy Toll of Poverty on Our Region’s Health. Residents of high-poverty neighborhoods in this region die on average ten years earlier than residents of low-poverty neighborhoods, despite interacting with the same healthcare delivery systems.

Differences in social circumstances account for the unacceptable health inequities evident in health outcomes nationwide. There is a growing number of federal mandates and recommendations that encourage healthcare workers to consider and address health equity factors and SDOH. These include CMS health equity measures, The Joint Commission’s Healthcare Disparities Reduction and Patient-Centered Communication Accreditation Standards and the U.S. Department of Health and Human Services’ Office of Minority Health National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare.

HANYS’ new Health Equity crosswalk provides a single reference point for these hospital equity measures, standards and requirements.

Taking steps to address SDOH

Health systems are realizing that to address social determinants in patient care, they must first assess each individual’s social drivers. Many health systems have begun screening for SDOH, including asking if a person has safe and long-term housing, enough food to last for the month and access to reliable transportation. Care teams can now record SDOH as ICD-10-CM Z codes, which categorize circumstances other than disease or injury. By capturing standardized data on factors like employment, isolation, veteran status and other social determinants, health systems can begin to quantify and address non-medical barriers to better health.

Identifying needs is just the first step. Providers can address these needs with patients and assure connection to resources, either directly or through a social work referral. For example, providers can discuss 211 Lifeline as a resource for social supports.

Some institutions have gone a step further to create immediate access to resources, such as an emergency food pantry inside the health system or emergency temporary housing to support homeless patients at discharge. Of course, linking patients to resources is a reactive solution to an existing circumstance. We must look upstream to identify and correct the root of the problem.

Systemic change

How do we end poverty? Obliterate racism? Eliminate food insecurity? Create thriving educational systems? This requires systemic change through advocacy beyond the walls of the hospital. Standing up for issues that protect the well-being of people in our communities is central to the role of a healthcare provider.

Those who work in healthcare should learn about their patients’ communities and begin to work toward social change that will impact their patients’ health. Health systems should engage community partners to gather insights from people impacted by their programs and policies.

Investing time, energy and financial resources to improve the SDOH for under-resourced people and communities is an efficient and effective way to impact population health and begin to eliminate health disparities.