Responding to the Changing Face of the Social Determinants of Health
2018 was the year of the Social Determinants of Health (SDoH), especially for the health care industry, with 2019 to be a repeat. These are the conditions in which people are born, grow, live, work, and age shaped by the distribution of money, power, and other societal resources at global, national and local levels. These non-medical factors contribute to adverse health outcomes; food insecurity, economic uncertainty courtesy of unemployment or disability, housing insufficiency, access to care, health literacy, and social isolation, to name a few.
Some facts about the industry impact of these SDoH:
· attributed to 5% of the population, and
· Responsible for 50% of hospital readmissions.
· are evolving SDoH related programming.
o 42% integrating community programs and resources into their population health programs.
o 34% combining census and socioeconomic data with clinical data.
· Increased vertical mergers address food, housing, pharmacy, mental health, and fitness deserts
o The to study the Zip Code effect, expanding contracts with Lyft Walgreens
o The collaboration
o Kaiser Program
o Montefiore Program
· Expanded ICD 10 Coding reimbursement by:
o Use of non-physician documentation by members of the interprofessional care team to substantiate and assign the ICD10 Z Codes (55-65) for payment, and
o Implementation of Human Trafficking, ‘T’ codes, also with clinical and appropriate documentation to substantiate (physician and non-physician).
Several months ago, I presented at a conference where an attendee posed an important point. In discussing the populations impacted by the SDoH, he felt education was in order about their changing face. He was aware of countless populations beyond the traditional scope who were impacted, and at times felt his colleagues viewed the SDoH from too traditional a lens. I emphatically agreed, and discuss this topic in upcoming articles, as well as my next book. Here are some current facts about that changing face.
Who’s Joined the SDoH Population?
Rapidly shifting population demographics have few persons now excluded from the SDoH ranks. Focus on society’s most vulnerable and disenfranchised members has been a constant theme of health care organizations.For years, hospitals and clinics had deep pockets to support, finance, and provide care for all who needed it. Though the current socioeconomic issues faced by clients often exceed what can realistically be provided. These needs have prompted a ripple effect on clinical treatment outcomes, only 10% caused by medical conditions. Even those organizations with the largest budgets and resources are challenged. The ethical dilemma of who lives and who dies has become a major theme for most health care organizations and their employees.
Along with the traditional populations dealing with the SDoH, new attention is on:
· Victims of natural and/or man-made disasters,
· Women experiencing health and gender equity issues
· Residents of rural health regions
· Persons faced with a sudden change in financial status or loss of income due to business closures and government shutdowns, plus older adult who lose pensions
· Persons faced with
· Members of the faced with
· Adults (e.g. physical, intellectual, mental illness)
· Victims of human trafficking
Make no mistake that each of these populations struggle with the socioeconomic and
psychosocial circumstances associated with the SDoH. Compelling numbers and concerns
live in the URLs provided. These population shifts mandate professionals and their
organizations expand the lens used to consider, assess and account for the SDoH as a
Addressing the ‘Big B’
Bias is a personal view that involves unreasoned judgment. In my new Ethics book, The Essential Guide to Interprofessional Ethics in Healthcare Case Management, I refer to bias as the 'BIG B'; it appears on a regular basis, impeding the ability of the interprofessional workforce to view client circumstances objectively. Bias creeps in when we least expect it. Think how often you may have referred to any of your clients in this way or heard a colleague refer to them as:
• “OMG, what a train wreck!”
• “I got another one of those homeless alcoholics”
• “Dang drug users”
• ‘NOT ANOTHER BORDERLINE!’
• “ That non-compliant diabetic mess from last month is back”
• “Mrs. J is back, and that lazy, unemployed daughter of hers”.
There is much we don’t know about our clients. The rapid pace most practitioners work easily leads to making quick assumptions about clients. Most likely the ‘trainwreck’ of a client didn’t ask to return to the hospital. How have we assessed why’? Perhaps the person with diabetes has a health literacy issue that impacts understanding treatment recommendations. Did we ask the client directly or did the BIG B invade with an assumption? Maybe our homeless alcoholic prefers living on the street to being in a shelter; he may be guarded with professionals due to past experiences when treated with disrespect by a provider. One wonders if Mrs. J’s daughter is unemployed to care for Mrs. J. or perhaps a child with disabilities on a Medicaid homecare waiver and receiving her own services. How much does untreated mental illness and stigma factor in for our client who presents with borderline traits. We don’t know what we don’t know.
Bias can equally cause us to ignore the new face of the SDoH. For example, consider Mary, an 88-year-old woman from a small rural community. A widow for 10 years, Mary lives on Social Security of $980 a month. She planned on her husband’s pension, but the company filed for bankruptcy. Her income covers taxes, food, insurance, and other expenses (e.g. medication co-pays, dental care, out of network costs for her rheumatologist; the provider in her region recently retired and another MD has not been found to replace him.) Mary eats 2 meals most days to extend her food supply. Some days she eats one large meal, supplemented by tea and fruit. Mary has two sons: one died in an accident 5 years ago and she is estranged from the other. Many peers have died, and she is sedentary and isolated. She spends her days watching TV or reading. This is Mary’s reality; none of it her fault. We don’t know what we don’t know.
Bias isn’t intentional, and most times unconscious. Part of the challenge (with bias) stems from it being associated with the personal values we grew up with, whether from our families of origin or friends. It becomes easy to not realize how out of sync our values are with those of our clients or colleagues. Our values may be different, though not necessarily wrong. Bias and our values become an issue is when they impact and/or interfere with providing care and intervention to clients. Remember client autonomy is always paramount, even if we disagree. As long as clients are capable of making decisions, we need to let them. Autonomy is about what the client wants, not what we want for the client, as well-intended as our efforts may be.
What can you do?
The current generation of needs are so pervasive they can easily leave the workforce feeling their efforts won’t make a meaningful difference to the client’s outcome. I’ve been employed in the health care industry for close to 40 years. There has always been unmet client need; some issues I was simply unable to resolve or fix despite all efforts. There will also be clients who don’t want our help. But, there are many times we wish we could do more. The question beckons across every practice setting and professional discipline; in the ethical context of practice did you do your due diligence to assure that client health, wellness, and safety were promoted?
Consider the following questions to guide your work with clients:
· Did you explore and provide all possible resources at your disposal?
· Did you call a resource on behalf of, or perhaps with the client to assure appropriate linkage?
· In what way did you advocate for the client?
· How did you assess and address:
o client engagement?
o client motivation for treatment?
o client health literacy?
o client or family lack of understanding of the illness impact?
· How did you explore/advocate/exhaust service provision at the:
o Micro level (within your organization, system)?
o Mezzo level (community and other programs or providers)?
o Macro level (public policy advocacy, exploring grants to address service gaps)?
The BIG B can easily be imposed on clients and their circumstances. There will always be clients whose needs are beyond available resources or who initially refuse help. However, we are each accountable to assess what motivates client engagement, try to understand those circumstances, and intervene to the best of our ability to address those circumstances and prevailing gaps in serviceprovision.
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