Collecting and Applying Data on Social Determinants of Health in

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Collecting and Applying Data on Social Determinants of Health in
SPECIAL ARTICLE
HEALTH CARE REFORM
Collecting and Applying Data on Social
Determinants of Health in Health Care Settings
Laura Gottlieb, MD; Megan Sandel, MD; Nancy E. Adler, PhD
D
espite strong evidence linking patients’ social circumstances to their health, little guidance exists for health care practitioners and institutions on addressing social needs
in clinical settings. Current approaches to social determinants generally focus on population-level and policy interventions; these overlook individual and clinical innovations within health care that can address patients’ social circumstances. This article proposes a framework for how social determinants interventions in the health care system can be construed across
3 tiers—patient, institution, and broader population—and describes ways to collect data and target interventions at these levels.
JAMA Intern Med. 2013;173(11):1017-1020.
Published online April 29, 2013.
doi:10.1001/jamainternmed.2013.560
Exponential growth in research on social
determinants of health over the past 2 decades has fueled interest in the possibility that intervening on environmental and
social exposures could improve health and
reduce health care spending.1 Many health
care professionals have equated addressing social determinants of health with acting on “fundamental” upstream causes of
disease that lie outside the health care system.2 But upstream efforts, while important, largely ignore the potential for medical professionals to address social
determinants within the health care delivery system. Modifiable social problems such as housing and food insecurity, which have been linked to health
status and health care utilization, can be
addressed in clinical settings as well as at
a policy level. Yet, little serious discussion has occurred about the multiple roles
that health care organizations can play in
directly acting on social determinants of
patients’ health. Articulating these roles is
increasingly relevant to hospitals given the
emergence of accountable care organiza-
Author Affiliations: Department of Family and Community Medicine (Dr
Gottlieb) and Center for Health and Community (Drs Gottlieb and Adler),
University of California, San Francisco; and Departments of Pediatrics and Public
Health, Boston University, Boston, Massachusetts (Dr Sandel).
JAMA INTERN MED/ VOL 173 (NO. 11), JUNE 10, 2013
1017
tions and related financial incentives to
keep patients healthy, in addition to the
2012 tax code from the Internal Revenue
Service requiring nonprofit hospitals to report regular community needs assessments and to establish plans for addressing identified needs.
INTERVENTION TIERS FOR SOCIAL
DETERMINANTS OF HEALTH
Reflecting lessons from early community
health center pioneer Dr H. Jack Geiger3
and the National Center for MedicalLegal Partnership (http://www.medical
-legalpartnership.org/), we propose the
concept map presented in the Table as a
guide for health care organizations and
practitioners to act on individual, health
care institution, and population levels to
affect health. The framework includes (1)
individual-level interventions that may immediately and directly affect patients’ social situations; (2) system or institutional interventions affecting populations
over which health care organizations have
responsibility, including patients and employees; and (3) community- or societallevel interventions, including social and
political advocacy and research.
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Table. Three Intervention Levels on the Social Determinants of Health for the Health Care Sector
Target
Patients
Institutional Populations
Goals
HCO applies SDOH to interventions
directed toward individuals
Potential levers
Adjust individual disease risk according
to known social determinant risks;
co-locate medical and public
health/other government programs;
improve referrals to off-site partners
Intervention examples
Use medical assistants to refer
food-insecure patients to food
benefits programs; provide legal
services through medical-legal
partnerships
Community
HCO applies SDOH data to direct
intervention toward patient and
employee populations
Report SDOH, health status, and
utilization data on institutional
population groups; apply social
determinants data to institutional
policies and practices; improve
systems and interventions to address
social/environmental factors for
institutional populations
Provide on-site farmers markets; offer
physical activity subsidies or
programs for members; include a
utility protection letter designed by
medical-legal partnerships in
electronic health records; offer living
wages to all employees
HCO influences policy debates or other
community change processes
Ensure data systems coordinate with
relevant government, policy, or
advocacy organizations; use
aggregated data to influence policy
decision making
Lobby for increased cigarette taxes;
promote healthier food benefits
packages; advocate for Healthy
Streets redesign
Abbreviations: HCO, health care organization; SDOH, social determinants of health.
Below, we suggest strategies for
integrating these levels of social interventions into traditional health
care delivery.
USING SOCIAL
DETERMINANTS OF HEALTH
DATA IN CLINICAL SETTINGS
Several key steps are needed to address social determinants of health
within the clinical arena.
Screening for Social Needs
Improving collection of social data
inside clinical settings is a necessary step toward translating the proposed intervention levels into practice. The vast majority of medical
providers working in underserved
settings believe social needs screening is effective for improving health.4
Just as data on symptoms and medical and family history are routinely
collected to inform diagnosis and
treatment, data on patients’ social
circumstances need to be collected
and tracked. Evidence to date suggests that the criteria of sensitivity,
feasibility, and “actionability” can be
met for specific social screening measures and interventions, and recommendations have been made regarding potential social data domains and
the appropriate frequency of data
collection.5
Applying Social Needs Data
Patient social data, once collected,
can be used to affect medical risk and
treatment decisions and to inform interventions to improve vulnerable
patients’ social circumstances.
Adjust Individual Disease Risk. Patient social data can influence clinical care decisions. Fiscella et al,6 for
instance, treated poverty as an independent risk factor for heart disease
and incorporated patient income into
10-year Framingham Risk Score calculations. Doing so better identified
patients at risk of developing cardiovascular disease than did traditional
calculators. Socioeconomic indicators also can enhance the utility of
specific screening recommendations and algorithms. For example,
adjusting for education improves the
accuracy of the Mini-Mental State Examination in predicting disease likelihood.7
Address Social Determinants
of Health. Beyond improving risk assessment and informing the use of
conventional medical treatment, social data can be used to guide on- or
off-site referrals in an effort to improve patients’ modifiable social
circumstances.
Co-Locate Health and Social
Services. Some health care settings
JAMA INTERN MED/ VOL 173 (NO. 11), JUNE 10, 2013
1018
have co-located on-site emergency
food boxes, farmers markets, or Special Supplementation Nutrition Program for Women, Infants, and Children offices to address hunger and
nutrition. Others have co-located
health and legal services through
medical-legal partnerships, which
address health-related legal needs—
such as unsafe housing or denial of
insurance—within the scope of clinical services. Health and social service co-location can provide increased consumer utilization and
program efficiencies.8
Tools to address social needs may
be incorporated into standard clinical protocols at the organizational
level. For instance, Boston Medical
Center’s electronic health record includes a legally formatted letter template to protect utility services (eg,
heating or air conditioning)9 (Table).
Such a letter can help a patient with
cold-induced asthma from worsening symptoms in winter or enable
medication refrigeration. Access to
a common template improves clinical efficiency by lowering provider
time demands.
Improve Referral Capacity. Despite the aforementioned examples, most social services reside
outside the health care system, and
social workers are used to link patients with these services.8 However, social work provider short-
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ages, lack of standardization, and
poor geographical and racial/
ethnic diversity may limit their effectiveness.10 Alternative models are
being developed that expand the capacity of providers and systems to
link patients to needed services at
lower costs. These range from improving resource information availability (https://www.helpsteps.com
/home.html and http://cap4kids.org
/philadelphia/) through use of
technology to training college student volunteers to connect patients
with community-based resources
(http://www.healthleadsusa.org/).
OPPORTUNITIES
AND BARRIERS
and effectiveness will require particular attention. Despite the recent surge in social determinants research, little analysis of ethical
challenges surrounding routine data
collection has occurred, and interventions have been inadequately
studied for their effectiveness. Incorporating social data and interventions into health care settings
should result in improved health status and lower health care costs and
utilization; achieving this will require documenting expected benefits while addressing privacy
concerns and other barriers to collaboration.
CONCLUSIONS
Existing guidelines for patientcentered medical home standards
and meaningful use of health
information technology focus on
integration of medical services
and data within and across health
care providers and sites. Recommendations here capitalize on federal mandates for service integration to include data collection on
social determinants and resource
integration within and across
health care and non–health care
agencies. These highlight a key
difference between a “medical
home” and a “health neighborhood.”11
Health care and non–health care
agencies could overcome barriers
posed by separate funding streams
by creating shared funding and
reimbursement agreements. Electronic health records could facilitate these intersectoral partnerships, particularly if they capture
some of the social and behavioral
factors that shape health. Initiatives supporting clinical transformation in the American Recovery
and Reinvestment Act of 2009 and
the Affordable Care Act of 2010
expand the potential for piloting
and scaling these collaborations.
Reimbursement opportunities for
these activities may emerge in
Medicaid Administrative Activities
matching programs and other federal reimbursement strategies that
improve access to services for Medicaid enrollees.
As social and health services integration diffuses, issues of privacy
As implementation of the Affordable Care Act proceeds, 32 million
previously uninsured Americans will
enter the health care system, most
of whom will be low-income or otherwise socially vulnerable patients.
Both the overlap and distinctions between social determinants of health
interventions and population health
approaches are relevant to help meet
these patients’ needs and to alleviate worsening societal cost burdens. Health systems must now take
the critical next steps, tracking and
addressing social factors at individual and institutional levels. Doing so can improve care for such
high-risk patients and inform policy
and advocacy actions that influence population health.
Accepted for Publication: January
28, 2013.
Published Online: April 29, 2013.
doi:10.1001/jamainternmed.2013
.560
Correspondence: Laura Gottlieb,
MD, Department of Family and
Community Medicine, Center for
Health and Community, University of California, San Francisco,
3333 California St, Ste 465, Campus Box 0844, San Francisco, CA
94143-0844 ([email protected]
.edu).
Author Contributions: Drs Gottlieb
and Sandel had full access to all the
data in the study and take responsibility for the integrity of the data
and the accuracy of the data analysis. Study concept and design: All authors. Acquisition of data: Gottlieb.
JAMA INTERN MED/ VOL 173 (NO. 11), JUNE 10, 2013
1019
Analysis and interpretation of data:
Gottlieb and Adler. Drafting of the
manuscript: Gottlieb and Sandel.
Critical revision of the manuscript for
important intellectual content: All authors. Obtained funding: Gottlieb and
Adler. Administrative, technical, and
material support: Gottlieb and Adler.
Study supervision: Gottlieb and Adler.
Conflict of Interest Disclosures: Dr
Sandel reported serving as the Medical Director of the National Center
for Medical-Legal Partnership at the
George Washington University
School of Public Health and Health
Services.
Funding/Support: Support for this
project was provided by the Lisa and
John Pritzker Family Fund (Drs
Gottlieb and Adler), The Kresge
Foundation, and Robert Wood Johnson Foundation (Dr Sandel).
Disclaimer: No funding agency
played any role in the design and
conduct of the study; collection,
management, analysis, and interpretation of the data; and preparation,
review, or approval of the manuscript.
Additional Contributions:
Stephanie Stoner, BA, provided editing assistance on the manuscript.
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Images From Our Readers
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Houston, Texas.
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