EXECUTIVE SUMMARY

Patients’ underlying social and personal issues — known as social determinants of health — can affect their hospital lengths of stay, readmissions, and overall health.

• Housing is one of the chief social determinants of health, affecting patients’ ability to take medication, eat well, and reduce stress.

• Food insecurity also can negatively affect patients’ health if they live in an area where it is difficult to find healthy, fresh food.

• Social exclusion can result in patients having too little physical and emotional support, also increasing health risk.


Sometimes the most sensible way to reduce hospital lengths of stay (LOS), readmissions, and ED visits is to tackle the underlying social and personal issues that confound patients’ lives.

These social determinants of health are becoming better known in case management — yet, the connection between these and health outcomes are less well known.

Case managers often do not have the time it takes to understand every patient’s story well enough to help them solve major nonmedical problems and health access barriers. But they can help patients whenever possible by focusing on their specific barriers and helping them improve what can be improved, says Karen Nelson, MSW, MBA, director of social work and case management at Stanford Healthcare in Palo Alto, CA.

After Stanford Healthcare began to address patients’ social determinants of health, the health system was able to reduce the number of hospitalized patients with 30-plus day lengths of stay (LOS). Out of the hospital’s 430 beds, there were more than 30 inpatients with longer LOS, and now there are 24-25 hospitalized patients with 30-plus-day LOS.

“We set a new target last year to have less than 25 patients in the hospital at any given day who have been there for 30 days or longer,” Nelson says. “And we’ve only had one month where the number of patients with long lengths of stay exceeded 25; the average recently was 22 patients.”

The case management program pulls together various disciplines to help reduce long lengths of stay, including rehabilitation, nutrition, social workers, nursing, spiritual care, respiratory therapy, and physician medical students. Social workers help patients with housing, addiction, and family conflict, and case managers know what the patient qualifies for and what resources are available for the next level of care, she says.

Nelson speaks at national conferences about social determinants of health and offers the following explanations for various types:

• Housing: “Clearly, people who are underhoused or without housing have a great deal of difficulty keeping appointments, following through on treatments,” she says.

People who live in overcrowded or unsafe housing or insecure housing — in which they are daily at risk of eviction — will find it difficult to keep track of their medications and health practices.

Case managers sometimes come to the realization that the person they’re trying to help stay healthy despite diabetes cannot focus on his or her diet or medication because of the fear of losing his or her home.

“Some places where people live are dangerous to their health,” Nelson says. “It’s a total demonstration of social determinants of health.”

• Income: “People with a greater income can mitigate a lot of the bad things that happen in life,” Nelson says. “They can throw money at problems, so if their car breaks down, it’s just an inconvenience.”

By contrast, someone whose income is very low might have to take a bus when the car breaks down.

Being low income or perceiving that one’s income is lower than neighbors or peers can lead to stress that impacts health, she says.

“You might spend a good part of your day fretting over things,” Nelson says. “Stress is not good for your health: You don’t sleep well, you’re edgy, you’re worrying, and not relaxed.”

People do not make good decisions when they’re under stress, and they have difficulty focusing on living a healthy lifestyle, she adds.

• Food security: Patients who lack adequate nutrition or do not have access to the right foods and special diets will experience worse health outcomes, Nelson says.

“Maybe someone is selecting foods that are very bad for their health,” she explains. “People think that people who are food insecure are going to be thin, but what happens is that many people who are food insecure are overweight because the foods they eat are the cheapest, but not the healthiest.”

People will go to the corner store to buy groceries because they can walk there. This means they pay more per item and have a less healthy selection of food. It’s possible to find healthy foods at drug stores and corner markets, but they’ll have to be selective because there won’t be a full range of vegetables as they might see at the grocery store, she adds.

• Social exclusion: Patients who live alone and are socially isolated may need family and community support. Their health and well-being are enhanced by being with people who care about them and support them, Nelson says.

“If people are caring about them in a way that feels constructive, they’ll experience better health,” she says. “Some of the impact is psychological.”

This dynamic also benefits patients because there’s someone who is looking after them when they return home from the hospital.

• Work and education: Unless a person is working in an unhealthy or dangerous environment, work is a positive contributor to health, Nelson says.

“Employment leads to people contributing to society and feeling good about themselves,” she says. Also, earning money gives people freedom to buy what they want and need.

Education also can have a positive effect on health. “I tell students that going to school is one of the best things they can do because education is a healthy lifestyle,” Nelson says.

Education is a positive factor. It gives people choices in terms of employment and can contribute to better self-esteem, energy, and quality of life, she says.

Alternatively, patients who lack the daily experience of employment, volunteer work, or education might suffer healthwise from even more isolation or the lack of a sense of purpose.

• Poor early life experiences: “Poor early life experiences can impact a person’s health quite significantly,” Nelson says.

These might include childhood trauma, abuse, poor nutrition, and lack of stimulation. Adults who suffered from these problems might not develop psychologically or educationally as well as they should.

“What tends to happen is they have low self-esteem,” she says.

This can lead to poor lifestyle decisions, including entering bad relationships, living an unhealthy lifestyle, addiction, etc.

Understanding these factors is a first step. The next step is for case managers to resolve these social determinants of health issues as a part of their overall goal to improve patients’ health.

Finding patients help with housing, employment, food resources, and other needs can help improve their health.

“Case managers can connect patients to the community to work with them to obtain housing,” Nelson suggests. “This can be very useful, and we can write letters [to housing authorities] on behalf of patients, commenting on how their health is impacted.”

Case managers also can help connect patients with food banks, Meals on Wheels, public transportation, and psychosocial services.

“We can engage patients with community agencies and groups that offer community activities and socialization to address isolation,” Nelson says.