How Do Social Determinants of Health Affect Patient Wellness?

Transportation

Transportation has an effect on patient wellness because it directly impacts whether or not a patient can access her healthcare. When a patient has transportation barriers, she is less likely to attend a wellness check, chronic disease management appointment, or follow-up care.

In 2017, 3.6 million individuals missed an appointment because they did not have access to transportation to that appointment, according to figures from the American Hospital Association (AHA). Four percent of children missed their medical appointments for that reason.

Patients who don’t go in for wellness checks could miss a serious diagnosis. Patients engaged in chronic disease management might miss a key metric indicating a problem. Similar issues arise for patients who need post-acute follow-up care.

And when any of these more minor warning signs fall under the radar, the patient runs the risk of incurring a more costly and invasive health episode in the future.

Many healthcare organizations are attuned to this medical transportation problem. Popular rideshare companies, like Uber and Lyft, have emerged as key community partners in tackling medical transportation. These rides have proven significantly more cost-effective than letting a patient’s condition become uncontrollable. Studies also show they can reduce the no-show rate, which has a business benefit for providers.

Other more niche non-emergency medical transportation (NEMT) companies have also sprung up in recent years, providing rides to care that is more specialized than rideshare but less extensive than an ambulance.

Housing

Housing, too, has a direct correlation with health and wellness. The connection here is twofold.

Experts foremost refer to Maslow’s Hierarchy of Needs, explaining that individuals who are worried about finding a safe place to sleep are not necessarily concerned about their health and wellness. It is harder to manage chronic illness, adhere to wellness checks, or access simple preventive care like a flu shot when one is looking for an open homeless shelter.

Second, individuals who are houseless or housing insecure are more likely to have those chronic illnesses.

“Chronic medical problems that are prevalent among adults experiencing homelessness include seizures, chronic obstructive pulmonary disease, arthritis and other musculoskeletal disorders,” Homeless Hub reports on its website. “Conditions such as hypertension, diabetes and anemia are often inadequately controlled and may go undetected for long periods. Respiratory tract infections are common and oral and dental health is often poor.”

What’s more, individuals who are homeless are at higher risk for certain illnesses by virtue of living on the streets or having an unstable housing situation. Tuberculosis, for example, is common among individuals who are homeless, Homeless Hub stated.

Healthcare organizations, again, are throwing their capital behind this problem. Kaiser Permanente has helped to fund a number of affordable housing complexes in the many areas across the country it delivers care. Other organizations with less community health funding have also worked to refer patients to more stable housing options.

Housing goes beyond having a house to live in, however. That house must also be conducive to healthy living. Unclean housing, housing with asbestos, and housing with poor air quality can lead to or exacerbate chronic illness, like asthma.

Patients who screen positive for this issue may receive a referral from their provider to a lawyer. Healthcare organizations call this a medical-legal partnership, and these lawyers help advocate for patients who need healthy living conditions.

Income

Income is a pervasive social determinant of health because it has a domino effect on several other social determinants of health. Income can impact:

• Educational attainment
• Healthcare affordability, payer status
• Housing status
• Access to nutritious food
• Numerous other domains

And in facing limitations in social determinants of health, it is challenging for patients to achieve wellness. According to a 2018 report from the Commonwealth Fund, patients with low income are more likely to experience chronic illnesses like obesity, hypertension, and diabetes. These conditions can often co-occur with some mental and behavioral health diagnoses, like depression or substance use disorder (SUD).

What’s more, low-income patients with co-occurring illnesses spend more on their healthcare than those with higher incomes. This suggests unequal disease burden, the report authors said.

Income inequality in and of itself is an expansive national issue, and currently most healthcare entities are addressing it by first addressing the social determinants of health income inequality effects. Community health partnerships promoting educational attainment, housing access, and food access are all important to closing the health-income gap.

Food security

Per September 2020 figures from the US Department of Agriculture, 10.5 percent of households were food insecure in 2019. For 6.4 percent of those households, food security was low, and for 4.1 percent it was very low.

Food security most prominently affects a patient’s ability to manage or stave off chronic illness. When a patient cannot access nutritious food, it becomes more likely they may develop a chronic disease like diabetes, or become non-adherent to dietary components of a care plan.

What’s more, limited food security can affect patient access to care. According to Feeding America, 66 percent of those Feeding America serves had to choose between food access and medical care.

On a federal policy level, many healthcare experts have lauded the Supplemental Nutrition Access Program (SNAP), which serves low-income individuals and helps them obtain meals. In 2017, researchers found that patients who use SNAP are less likely to be hospitalized, which has both financial and wellness benefits.

Some organizations are making it easier for patients to enroll in and access SNAP benefits. A program from Kaiser Permanente helps to navigate patients in the enrollment process.

For patients who do not qualify for SNAP, medical groups lean on community health partnerships with food banks to close access gaps. Providers who screen patients positive for food insecurity can refer patients to these food banks to promote access to nutritious food.

Family assistive services

As one of the most requested social services, family assistive services run a broad spectrum, according to data from WellCare Health Plans. These services can include family support, child welfare, and child care.

More specifically, WellCare pointed to a significant need for services that benefit a child directly. Nearly one in five referrals were for a child under the age of 18, and 12 percent were for a child under age 12.

Limited child care, child welfare services, and family support can overall stunt a child’s social and health opportunity, which can have an adverse effect on wellness into adulthood. Children need a safe home, access to nutritious food, and access to education in order to achieve wellness, evidence suggests.

But screening for social determinants for children can be particularly challenging. Guardians can be reticent to disclose any issues at home or that affect their children because they are worried a clinician may call child protective services. This comes even as parents and guardians know social determinants of health can impact childhood wellness, according to Public Agenda and United Hospital Fund.

Clinicians still need to screen for pediatric social determinants of health. After all, nearly two-thirds of children experience some sort of social determinant of health that affects their opportunity for wellness, according to separate data from Nemours Children’s Health System.

Providers working to establish trust between themselves, parents and guardians, and patients may consider the following:

• Being judicious about when to bring up SDOH, being careful not to have discussions in front of child patients
• Providing affirmations of confidentiality
• Being upfront and transparent about what topics would trigger a report to child protective services
• Explaining the purposes for asking about SDOH and confirm that these screenings are a part of standard appointment protocol

Clinicians who establish good relationships with pediatric patients and parents or guardians may more effectively flag social determinants of health concerns and can refer patients to helpful resources.

Utilities stress

Utilities stress is defined as challenges in paying for key household functions, like the water bill, electric bill, or heating bill. These utilities are what make a house livable, but payment can be extremely challenging for some populations.

Like other social determinants of health, it is difficult to capture how many patients report utilities stress. In fact, literature suggests most providers are undercounting these patients. According to a February 2020 study published in the Journal of Ambulatory Care Management, only 16 percent of the patients getting a shut-off warning letter from their utilities company — a signal that the patient could not pay their bill — screened for utilities stress during a medical appointment.

This comes even as clinicians screened 70 percent of patients for any social determinants of health, suggesting that many patients are falling through the cracks.

The reasons for this underreporting may be manifold. In the case of utilities stress, patients might only feel that stress during one part of the year. Utilities stress may be more pressing during the winter, when the heat consistently runs, than during the spring. Providers may also undercount patients because many who have utilities stress do not present for appointments.

And finally, patient trust is crucial. A patient may not report utilities stress because they experience embarrassment or have other hesitancies disclosing information to their provider.

For providers who do detect utilities stress in patients, they may connect with the utility provider to prevent having services shut off. A utilities protection letter would notify a service company that a patient has a chronic illness, and have some legal weight to prevent services from being turned off.

Race, discrimination

Race has long been regarded as a key social determinant of health, with most of the literature indicating that traditionally marginalized populations are more likely to experience other social determinants of health than White patients. Black and Hispanic patients may be more likely to be low-income, for example.

These are important points, but emerging evidence shows they do not account for all of the health disparities seen across the US healthcare system. When controlling for the social determinants of health, Black and Brown patients still see many outcomes gaps, which some experts have asserted can be credited to discrimination.

Implicit bias on the part of providers contributes to this. Although very few providers decide to treat a certain group of patients more poorly than others, unconscious bias may creep in and diminish patient care.

Per 2020 research out of the Regenstrief Institute and Department of Veterans Affairs (VA), Black patients have picked up on non-verbal cues that could suggest implicit racial bias. Factors like a mostly white clinic staff and strained patient-provider communication can get in the way of Black patients perceiving quality healthcare.

The medical industry is beginning to address this chasm with more cultural competency training and community health partnering with trusted leaders in communities of color.

Healthcare is also largely understanding racism as a public health crisis. Although the field of understanding is burgeoning, the concept of “weathering” might have a big impact on chronic illness.

Weathering is the idea that prolonged exposure to adverse conditions, like discrimination, can have an impact on chronic illness. The sustained stress could negatively impact patient wellness.

A July 2020 report gives credence to that concept. The American Heart Association found that individuals with reports of discrimination were more likely to develop hypertension.

To be clear, racism is a national crisis that permeates numerous areas of everyday life. Healthcare is only one part of that, but it needs to own that part, the American Heart Association researchers said.

“Our findings highlight the need for health care professionals to recognize discrimination as a social determinant of health,” said Allana T. Forde, PhD, MPH, the study’s first author and a postdoctoral research fellow at the Urban Health Collaborative at Drexel University in Philadelphia, Pennsylvania.

“Health care professionals who understand the importance of unique stressors like discrimination that impact the health of African Americans will be better equipped to provide optimal patient care to this population.”

The momentum for social determinants of health has reached a tipping point. What was first a buzzword about value-based care has turned into actionable transformation in the healthcare industry.

As providers continue to embrace interventions to address social determinants of health and promote patient wellness, it will be important to measure intervention efficacy to make prolonged improvement.