By Jeni Miller
Social determinants of health (SDOH) are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks,” according to health.gov.1 These fall under five domains, including economic stability, education access and quality, healthcare access and quality, neighborhood, and relationships/social context.
Case managers assess and consider SDOH from the moment a patient enters the hospital. That consideration continues throughout the stay and discharge process. When SDOH go unnoticed or unaddressed, the quality of care declines.
“Not addressing SDOH leads to health issues,” explains Bonnie Geld, president and CEO of The Center for Case Management (CFCM). “People need to make tough choices. For instance, people with chronic conditions often require special diets. For those with food insecurities, they are forced to make poor choices, resulting in poor health or potential hospitalization.”
Thomas Higgins, MD, MBA, FACP, MCCM, chief medical officer for CFCM and ICU attending physician at Baystate Medical Center in Springfield, MA, has seen how SDOH plays out.
“If you’re caring for a diverse group of patients, you will notice that the same diagnosis can affect patients differently depending on their socioeconomic status, where they work and play, and their support networks,” Higgins explains.
Historically speaking, this is not a new development. “John Snow, a pioneer of epidemiology, stopped a cholera outbreak in 19th century London by recognizing a neighborhood well was contaminated,” Higgins says. “At a basic level, then, medical diagnoses can be related to the neighborhood where you live. Environmental exposure to toxins can be subtle but significant.”
Higgins also cites an example of how understanding neighborhood or built environment SDOH can make a difference in how a case manager approaches a patient’s care.
“Early in my career, I worked near the Tobin Bridge in Boston. It was well-known that lead levels were highest in children living closest to the bridge, which was periodically scraped and repainted, releasing lead into the environment,” he recalls. “Left untreated, lead poisoning causes long-term neurologic damage. If you’re aware of these geographic sorts of dangers, you can more efficiently protect the population at risk. You might screen for lead levels more aggressively in an inner-city environment where there is still lead paint in older housing.”
Of course, it is not only the patient who is affected by SDOH. The hospital or organization as a whole feels the effects of unaddressed SDOH. Geld notes this can lead to “organizational capacity and financial challenges.”
For example, “35-45% of discharge delays and 25% of readmissions are due to SDOH issues,” she explains.
Since both the patient’s and hospital’s well-being are important to the healthcare team, a team approach to SDOH is critical to the health of the organization and those who are served by it. For Higgins, quality communication with a vigilant case manager recently played a key role in helping properly treat a patient — and, perhaps, prevented a recurrence and readmission.
“Every member of the healthcare team has a piece of the puzzle, but value is created only when we share those impressions, including the social determinants of health,” Higgins explains. “Last week, I had several patients present with drug overdoses. The case manager shared that one patient swallowed a handful of pills in a dramatic gesture when confronting her husband with suspected infidelity. That’s going to require a whole different post-discharge approach than an accidental overdose where fentanyl was contaminating what the patient thought was cocaine. Each of these patients came to me intubated and unconscious, but their long-term success is going to depend on properly addressing their underlying issues.”
COVID-19 as a SDOH
SDOH became a renewed topic for discussion when COVID-19 showed the world just how important risk factors can be, whether medical or social.
“Prior to vaccines being available, one of the biggest risk factors for getting COVID-19 was living in a conjugate setting such as a nursing home, group home, or long-term care facility,” Higgins says. “COVID had a devastating impact on people with intellectual disabilities, even those not living in group settings. The risk of getting COVID has been dramatically mitigated with vaccination, but we need to remember these lessons for the next pandemic, and in communities where people are still vaccine-hesitant. There’s no doubt that living in close quarters, pre-existing respiratory illness, diabetes, obesity, and kidney disease are risk factors for COVID. Many of those factors correlate with SDOH.”
For Higgins, the lessons do not stop there. The COVID-19 pandemic itself has become a SDOH in part because of the isolation and substance abuse that has quickly escalated over the past year.
“I’ve been an ICU attending [physician] for almost 35 years, and I’ve never seen the volume of alcoholism, cirrhosis, endocarditis, and drug overdoses we’re seeing now as COVID begins to wind down,” he laments. “I’ve seen some estimates that overdoses are up 30% in the past year, and that might be undercounting based on my experience. COVID has decreased access to medical care for the past year, and there will be adverse effects from delayed screening for cancer diagnosis, an increase in substance abuse, poor diet, and mental health issues for months, if not years, to come.”
It is not a hopeless situation. Social workers and case managers can use several tools to uncover SDOH and address them appropriately. Geld points to several interventions that can help case managers better understand the patient’s story and circumstances:
- Use a family-centered SDOH screening tool;
- Ensure good psychosocial interventions;
- Identify needs as early as possible in the patient’s stay;
- Develop and sustain interventions through team-based care and community collaborations;
- Use grassroots advocacy efforts.
In practice, case managers should be attuned to how their interventions can affect the patient’s success following a hospital discharge.
“It might be as apparent as the need to find a place for a homeless patient following hospital discharge, or less obvious, such as when a patient lives in a ‘food desert’ and can’t access nutritious food choices,” Higgins says. “There have been a few peer-reviewed studies that show if you invest in social services and integrated models of healthcare, you’ll improve outcomes and save money overall, although admittedly you can find negative studies as well. But the more important issue is that patient care suffers if SDOH aren’t addressed. Case managers have the knowledge and experience to anticipate care problems and address them.”
These interventions can affect acute care or long-term care. For the former, a hospital case manager might register a patient for Medicaid or help her manage “other issues that will prevent them from getting proper care after discharge, [including obtaining] durable medical equipment like oxygen tanks and concentrators, wheelchairs, rides to appointments, and so forth,” Higgins adds.
For long-term care, case managers can advocate for widespread change, like improved housing or transportation, psychiatric services, education, and the availability of healthier food options in the community.
Social workers and case managers should not underestimate their effect on patient outcomes. Employing their knowledge of SDOH can contribute to a positive effect that reverberates through a community.
“Of the entire healthcare team, case managers and social workers often have the best up-to-date knowledge about social conditions in the community because they are constantly arranging interventions with local providers,” Higgins notes.
Some of those local providers might include:
- alcohol and drug treatment centers;
- home health agencies;
- skilled nursing facilities;
- Veterans’ Affairs;
- Meals On Wheels.
“I’m at an academic medical center where there’s a constant stream of new residents and fellows from all over the world, and who may not yet have cultural knowledge about our patient community,” Higgins says. “We absolutely look to our case managers and social workers to be the subject matter experts on SDOH when we are doing multidisciplinary rounds.”
Geld sees the social worker and case manager as key to helping the rest of the team understand the whole patient. They also work to communicate the patient’s narrative in ways that may affect the treatment and discharge plan, which could make a difference for years to come.
“The role of social work is to learn and communicate the family story,” she says. “Through this, the patient’s true self can be integrated into developing a realistic and sustainable plan for the patient.”
- Healthy People 2030. Social determinants of health. Health.gov.