Moving Through the Hype Cycle on Social Determinants of Health
Is the concept of social determinants of health in danger of being overhyped? Certainly, enthusiasm for SDOH work is growing in both public and private payment models. In a recent talk, Laura Gottlieb, M.D., M.P.H., director of the Social Interventions Research and Evaluation Network (SIREN), made the case that it is up to researchers to work through the hype cycle and determine which types of social interventions actually have impacts on clinical outcomes.
Gottlieb, an associate professor of Family and Community Medicine at the University of California, San Francisco, was speaking Nov. 8 as part of Portland, Ore.-based OCHIN’s Grand Rounds series. Her research focuses on evaluating programs and policies that aim to increase healthcare system activities related to identifying and addressing social risk factors in the context of care delivery. SIREN advances research on healthcare strategies to improve social conditions and is working with other organizations to create some agreed-upon data standards for social determinants.
She cited three main reasons that SDOH momentum is growing so rapidly:
• Overall U.S. healthcare spending is so high and the outcomes are poor relative to spending. Gottlieb noted that compared to other large countries, our per-capita spending on combined health and social needs is not that different, but the United States spends much more on healthcare and less on social needs than other countries. “We are an extreme outlier in that ratio of spending,” she said. “Some people believe that ratio is driving our poor health outcomes.”
• We have reached a point where the evidence about how social conditions shape health outcomes have gotten to the point where we can’t ignore it, Gottlieb added. “We are increasingly aware that socioeconomic factors like poverty and the health behaviors shaped by poverty contribute more to future mortality than medical care. I think we can all agree that poverty itself is an independent risk factor for death. Men in the lowest income bracket will die 15 years earlier than men in the highest income bracket."
• The third reason that the healthcare system is increasingly turning to social care is because of the recent shift to value-based payment models in which providers are paid for outcomes, not just the delivery of services. “This shift has incentivized more healthcare delivery organizations to think more holistically about what produces health,” she said.
All of that together means that we are ready to start thinking about what it would take to address social conditions as part of our healthcare delivery system, Gottlieb stressed. “If you were to believe all the papers and presentations on social determinants, and follow all the experiments in policy and payment innovations emerging every week, you might think that assessing and addressing social risk in the healthcare delivery system was going to fix everything that ails our system,” she said. “I am from the Bay Area. I like to say that we are at the beginning of what is called in tech startup language the innovation hype cycle. The first phase of that cycle typically involves the peak of inflated expectations, where early publicity produces lots of success stories. But unfortunately that peak is often followed by what they call a trough of disillusionment, where early innovations don’t systemically deliver. As researchers, we are responsible for helping to move through that trough and up the slope of enlightenment.”
So what can healthcare systems do to address social conditions?
In 2018 through the fall of this year, Gottlieb and Rachel Gold, Ph.D., M.P.H., OCHIN’s research director, were on a committee of the National Academies of Sciences, Engineering, and Medicine that wrote a report on integrating social care into healthcare delivery. “We tried to explore the question of what the healthcare system should be doing around social conditions as a strategy for improving health,” she said.
The committee came up with a five-item framework to describe the way health systems are engaging on social conditions today.
• Awareness: Getting a better understanding of the social needs of their patient populations;
• Adjustments to clinical care to accommodate identified social barriers;
• Assistance: Activities that reduce social risk directly by providing direct assistance, such as providing food or housing support;
• Alignment: Activities undertaken by healthcare systems to understand community-level assets, organize with those assets to facilitate synergies and deploy them;
• Advocacy: Healthcare organizations work with partners to promote policies that facilitate new resources to address both health and social needs.
In terms of awareness, she said healthcare systems are increasingly gathering information about patients’ social context. These strategies are quite diverse. Some are asking about social risk in clinical settings. Some are buying big consumer data about your purchasing history, your home ownership, bankruptcy, or experience in the justice system, and others are mapping area levels of socioeconomic data and trying to cross it with address data they have on patient populations, she said.
In terms of gathering data on individuals in clinical settings, much of the research has been focused on patient-directed social risk screening tools. Gottlieb said there is a “vexing lack of consistency in these tools.”
Some of these tools are now being incorporated into major EHR platforms such as Epic. Sometime more than one of these is included as an option for providers. She noted that very few of these tools have been tested for the type of validity that researchers would expect of other clinical screening tools. “There is a lot of work left to be done, but we are increasingly seeing these being used in healthcare settings.”
In terms of intervention strategies, there are two main categories of adjustment and assistance. Adjustments are situations in which social risk information is used to inform clinical care. They may be right at the point of care or at the payment level. For instance, we might pay providers differently for treating those with social barriers or it could be addressed in quality measure incentives, she explained.
You don’t hear a lot of hype about adjustment strategies, Gottlieb said, but some of these are already in place to accommodate social factors, such as making sure patient information is available in languages other than English or at an appropriate literacy level. But she adds that these types of strategies for social risk-informed care are applied inconsistently. “We don’t think about those things for every patient every day. We haven’t developed protocols or studied them to understand what works best for whom. We need better evidence and more clarity about how to systematically apply these data to improve conventional care. And then we need to have the right social data available to providers and the right interventions built into our EHR.”
Another strategy is social risk-targeted interventions, or assistance, leveraging healthcare system resources to improve patients’ social context with the assumption that it will approve patients’ health and well-being. This could include food, jobs, transportation or housing. A health system might pay for housing support specialists or buy them an air conditioner. These kind of interventions are sometimes part of care, but are rarely routinely built into practice, she noted. “The evidence on these interventions is growing, but not where we want it to be,” she said. Research has been slow to grow. We know quite a lot about how social determinants shape health, but we haven’t seen as much yet in the way of evaluation of interventions.
There are a number of new health IT tools to enable these healthcare focused strategies related to awareness and adjustment activities. These include tools to ensure systematic, structured and standardized social risk data collection. “There has been a lot of energy devoted to ensuring we develop consensus on documentation codes or medical vocabularies that could be used to document social care activities undertaken in healthcare systems across organizations,” she said, “so that if you are screening for food insecurity at your institution and I am screening for it at my institution, on the back end, we can say, ‘Oh look, organization A and B are both collecting this information.’”
SIREN is looking to lead an initiative to determine what are the concepts around social determinants we need to have consensus on and that we need to have medical vocabularies to code them in our EHR for documentation.
As evidence emerges, Gottlieb said, perhaps there will be more clarity about the best role for healthcare organizations to play in terms of leading or being partners in these efforts.
Intriguingly, she closed by saying that there could be important unintended consequences of healthcare systems stepping into these roles, and there are plenty of unanswered questions, including about patients’ rights around social data acquisition and sharing. Also, if we use more resources for social care, are we undermining medical care?
“I don’t have answers to those questions,” Gottlieb said, “but they are high priorities for future research.”
