PHILADELPHIA — Fixing problems with people’s social determinants of health is an urgent issue for the healthcare community and beyond, Karen DeSalvo, MD, MPH, said here Tuesday at a Population Health Colloquium sponsored by Thomas Jefferson University.
“The stakes are really high,” said DeSalvo, who is professor of population health at the University of Texas at Austin and former National Coordinator for Health Information Technology. “People are dying prematurely … That’s worrisome to me as a citizen and a doctor and a public health professional. We’ve got to stand up and do better.”
But the answer won’t come in the form of a single drug or cure, she said. “No single sector can do this alone. It will take a multi-sectoral partnership between the public sector and the private sector. We have to begin to address the social and environmental and behavior factors that drive health … If we can affect social and environmental and behavioral factors that drive health, we can change outcomes … We can address hunger, we can address isolation, we can address transportation and begin to move the dial on not only cost and utilization but importantly, on health experience and health outcomes.”
DeSalvo gave examples of how government, academia, and healthcare organizations are starting to look at social determinants of health in terms of assessing the problem, providing assistance, and aligning resources:
- Assessment: The University of Arkansas is [extracting] notes from inpatient electronic health records — including nutrition notes, social work notes, occupation therapy notes, and clinical notes — to develop a “social risk score” for individuals. “Instead of asking folks, they’re trying to glean that from existing data that’s available,” she said
- Assistance: Humana in South Florida is performing a randomized trial to understand the best way to address food insecurity for the populations they serve
- Alignment: A total of 31 communities funded by the Center for Medicare & Medicaid Innovation are experimenting with how to align the food system, transportation system, and social care system to better serve populations, DeSalvo said. For instance, “Intermountain Healthcare [is working] in Utah in two communities to work collaboratively with public health, social care, housing, and transportation to identify gaps in service need and target Zip codes they want to improve … not just getting services to individuals, but really beginning to change the context,” she said. “The higher order of this work is around advocacy — how do you begin to change housing policy or the transportation system?” Likewise, Kaiser Permanente is working on this “not just to provide transportation for one patient to get to appointments but … to change the transportation system in the community so people are not only getting support to get to the healthcare system but to work or church or school”
“I think we’re just beginning to get a sense of how we’ll put the consumer at the center of the ‘Health 3.0’ world,” she said. “People sometimes think of disruption of healthcare from some disruptors like retail as stepping into the care delivery model or the supply chain but what I see in the work they’re doing is much bigger.”
“They’re working to become part of the ‘life flow’; they’re going to have a direct relationship with consumers, populations, and neighborhoods, and they are probably going to know about social determinants of health long before we can hand somebody a survey,” she continued. “That will give them a leg up on helping us identify that grandma is going to bed hungry or someone is having to use the healthcare system because their only transportation is the ambulance to the emergency room.”
“Those are no longer lofty ideas; they are starting to happen in the field,” DeSalvo said. For instance, “about 2 weeks ago, Molina [a managed Medicaid plan] announced it was purchasing Prime memberships on Amazon for Medicaid members so they can work on food delivery.”
DeSalvo said one of her concerns in the research on social determinants was that “we’re going to stick to the skinny evidence … [We need to publish] around population health, getting the work out there, even if it’s work that failed. Things that didn’t work we need to know about also.”
Another concern is that social determinants of health are being “medicalized,” she said. “If the medical system is responsible for providing transportation to the community, that transport would be to the healthcare system and not to work, for example … We don’t want people to be patients, we want them to be people.”
DeSalvo said she also wants to make sure that collecting information on social determinants doesn’t become too complex. She cited Humana’s “healthy days” module — a group of four validated, self-reported measures for patients — as a good way to get this information. “I’m concerned by recommendations of professional societies that doctors in particular should ask people if they’re going to bed hungry … A [long] questionnaire just adds time and burden.”
There are workarounds for this, including having health plan administrators ask questions by phone, or using existing data. Asking questions that go into a check box or making quality measures “would just sour the taste for everybody,” she said.