The outsized influence of social drivers on health
As physicians, we are trained to diagnose and treat illness. But all too often we know that the surface-level symptoms we address mask health risks that run much deeper. When an asthmatic child from an inner-city neighborhood makes repeat visits to the emergency department, the excellent care he receives works to stabilize him so that he can safely return home. But how long will it be until he returns?
Unfortunately, until healthcare advances, it will only be a matter of time – which is why this traditional model of care is no longer enough. To provide genuinely comprehensive care, physicians must look beyond the immediate to understand the true context of health. In the case of the young boy, his pediatrician would wonder why an otherwise healthy child requires regular emergency attention. He’d partner with local resources to look outside his diagnosis, and beyond his immediate symptoms, to check whether localized air pollution might be exacerbating his condition.
By knowing their populations, caregivers can ensure they can customize plans to help close gaps in care, limit the effects of SDOH, drive health equity, and advance preventive care that reduces costs. Only then will medicine be able to truly impact well-being, population health outcomes, and spend.
Providers looking to expand their approach to care can begin with these three steps:
1. Ask questions to improve outcomes at scale
Even if it seems simple, start with the basic questions: Are you eating enough? Will you have a ride to your follow-up appointment? Does this care plan make sense to you? By asking questions, you’ll unearth clues to the range of factors contributing to your patients’ overall health. By learning whether your patient can purchase enough fresh fruits and vegetables, you’ll learn a lot about how to improve their overall health. In so doing, you’ll reduce their long-term risk of chronic disease, such as diabetes, heart disease, or dementia. By providing clear instructions – and protocols – that make sense to your patients, you’ll increase their likelihood of compliance. For all these brighter outcomes, context – informed by the right questions – is key.
2. Right-size care by knowing needs
By understanding your patients’ whole health, not only will you be able to drive improvements in outcomes, but you’ll also be able to reduce healthcare spend. By providing preventive care, you’ll naturally help reduce the need for expensive hospitalizations and emergency room visits. When healthcare challenges inevitably arise, working to ensure individuals have access to routine care or care management can ensure the most appropriate level of care to meet their needs. In the long-term, and at scale, managing symptoms and keeping chronic conditions at bay will mean fewer intensive, emergency, costly resources. On a whole, any approach that addresses the gamut of invisible health drivers can also reduce the overall burden of disease, contributing to lower need, utilization, and cost over time. “
3. Think locally for life-changing care
Comprehensive care takes a “village.” By treating symptoms and identifying risks beneath the surface, physicians can act as a first line of defense for an individual’s long-term health. But, it takes targeted interventions and proactive collaborations to truly address SDOH and close these gaps in care.For example, physicians can partner with community organizations to help ensure their patients have access to vital resources, such as healthy foods or safe, stable housing. Caregivers can partner with schools and community organizations to provide patients with access to education, language translation services, and healthcare literacy classes. When providers and community-based organizations are in lockstep, individuals in need are truly supported.
Technology makes whole person health possible at scale
Years ago, physicians and other providers were limited in their ability to proactively address SDOH. Without an integrated technology platform to document clinical history, identify SDOH risks, connect with community resources, and “close the loop” on non-clinical referral requests, comprehensive care was difficult to sustain.
By uniting all relevant information for a “whole picture” of health, technology today makes comprehensive, preventive care possible on a whole new level. With these powerful tools, physicians are empowered to begin moving beyond the traditional model of care and toward a brighter, more equitable, and healthier system for all.
Terri Steinberg, MD, MBA, FACP, FAMIA, is the Chief Medical Officer and Chief Strategy Officer, for Medecision - a digital care management company whose solutions and services are used by leading health plans and care delivery organizations to support more than 42 million people nationwide