We’re going upstream! Dr. Karen DeSalvo (@KBDeSalvo) talks social determinants of health, arming us with a framework to consider this very challenging aspect of patient care. As Society for General Internal Medicine President and Chief Health Officer at Google Health, she shares her clinical and public health experience, including weathering Katrina in New Orleans. While our clinical care largely focuses on the downstream medical consequences, we must recognize the upstream social context to address the barriers to health and wellbeing.
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Written and Produced by: Emi Okamoto MD
Cover Art: Kate Grant MBChb, MRCGP
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Emi Okamoto MD
Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
Guest: Karen DeSalvo MD, MPH, MSc
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“Do the right thing until you get fired” -Dr. DeSalvo shares favorite advice she’s received
Per the WHO, social determinants of health (SDOH) are “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” (WHO, 2019). Healthy People 2020 categorize this in our neighborhood and built environment (environmental exposures, housing), education, economic stability (opportunities, status), social and community context (racism, provider bias) and health and health care (Healthy People, 2020). Surveys show more than half of Americans are affected by social determinants (Waystar, 2018). Anyone could be affected- regardless of their appearance, skin color, or the clothes they wear.
Dr. Desalvo’s advice: It is not our job to solve the SDOH, though we have a responsibility to understand it.
Unfortunately, it is difficult, expensive, and potentially unethical to do prospective randomized control trials on social determinants of health. Much of the evidence used in the field is expert opinion and consensus statements. It is often cited that SDOH may account for up to 80% of health outcomes (Hood, 2016). Some areas have stronger data, for example showing addressing food insecurity reduces health care spending or hospitalizations (Berkowitz, 2017; Berkowitz, 2019), though data is still needed for long-term health outcomes.
While there should be a conversation around SDOH, a formal screening questionnaire is not necessary and not recommended by Dr DeSalvo. Be with patients at the bedside, and demonstrate that we see them as a person and not a disease. Social screenings, done thoughtfully, are accepted by patients and may improve relationships (Byhoff, 2019). As well, it is important that providers contextualize our care plan to the patient and their needs.
Once social determinants of health are identified, it’s important to be able to act on the results! This may rely on team-based care or technology based solutions to facilitate referrals. Federally qualified health centers and patient-centered medical homes have built team-based models, and these should include warm-handoffs between social workers, nutritionists, and community health workers. In internal medicine wards, we should look to the success of cancer wards.
From the National Academy of Medicine report (2019), a framework can help think about integrating actions to address social determinants of health with the example of transportation:
Awareness: Ask how patients are getting to visits and necessary travel.
Adjustment: If transport is an issue, utilize tele-health or home visits when able.
Assistance: Link to transport vouchers.
Alignment: Invest in pre-existing programs providing transport services.
Advocacy: Advocate to improve the transport infrastructure to better serve the community.
Think about improving the interoperability of data between the healthcare system and partner community organizations to address needs. A system should be permissioned by the consumers, who can decide when and where data is shared. Organizations could include shelters, transportations services, and food banks. Aunt Bertha is a useful online platform of services; more integrated data-sharing has been done by Parkland. Watch out for more facilitated and automated closed-loop referral systems with feedback. Many more advanced options are being considered as well, like drones for food delivery… sky’s the limit!
Start thinking about this now! Certainly it’s important to our patients and their health outcomes. Also, quality metrics and payments systems are under development and testing to include social determinants. As providers, we must be engaged in the conversation and be partnering to solve the challenges.
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Listeners will recognize the ubiquity of social determinants of health and their effects on individual well-being and disease.
After listening to this episode listeners will…
Dr. DeSalvo was a former board member of Humana. The Curbsiders report no relevant financial disclosures.
DeSalvo KB, Okamoto EE, Williams PN, Watto MF. “#220 Social Determinants of Health with Karen DeSalvo MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 18, 2020.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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