Clinical Outcomes
Prioritizing social determinants of health is a must in value-based care
Author and Expert:
Dr. Nancy Yu
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When I started practicing medicine more than 17 years ago, splitting my time as an internist and pediatrician, I quickly became passionate about process improvement. Today, I practice at Southwest Medical, based in Nevada, where our group has been working in a value-based care model for over 30 years. As we became more sophisticated at value-based care over the last ten years, we learned that addressing the social and economic challenges of our patients was paramount to delivering patient-centric care.
This transition was critical for our clinics because delivering care has become more and more challenging. Our patients are struggling with growing social and economic challenges, and we are continuously working to detect and address those issues within and outside our clinic walls.
We’ve begun to uncover social determinants of health (SDOH) that help us create a more holistic roadmap to deliver better outcomes for our patients. In screening for SDOH using the modified Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) tool, we now have the data and insight needed to address problems such as lack of transportation, food insecurity, financial strain and social isolation. Our data indicates that those with transportation and food insecurity do in fact end up in the hospital more often.
Tapping a support system
The root of value-based care is delivering care that meets the unique needs of the patient, not just treating their symptoms. This means taking the time to understand their unique circumstances, including SDOH, and developing a comprehensive care plan.
We know a patient’s physical environment, social economic factors and even some of their behavioral choices factor into their clinical outcome. If we don’t address the issues that drive their clinical outcomes, then we are really undermining ourselves.
Addressing SDOH is not always easy. It requires healthcare workers to think beyond traditional medical interventions and work collaboratively with community resources and social services to address the root causes of a patient’s health issues. To effectively address SDOH, it’s also important to be aware of unconscious bias. This is where training related to bias can add significant value for clinicians and their teams.
It’s truly a team effort. Our front desk, medical assistants, social workers, dietitians, case managers and clinicians all play a part. They need resources at their fingertips so they’re not alone in identifying and connecting patients to the help they need outside of the clinic.
In our Nevada practice, we uncovered some patients who were having trouble managing their diabetes were also experiencing food insecurity. By obtaining this data, we were able to connect them to local food pantries and focus our efforts on teaching these patients about how to make healthy food choices. This not only makes a difference in their daily lives, but it also prevents negative downstream effects such as emergency room visits.
We’ve also experienced success with transportation resources. We need our patients without reliable transportation to make it to their check-ups, pick up their medication and continue their wellness plan. By solving one problem with rideshare services, we prevent countless others.
With these resources made available to us as part of a value-based care program and stronger community connections, it’s made a difference in how we treat our patients. Now we’re able to partner with our patients on care strategies, unique to them, that make the most impact and ultimately, improve their lives.
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Creating stronger patient partnerships
A great benefit of SDOH data is the insight it delivers to create a tighter relationship with our patients. With better patient intake data and predictive analytics, we’re able to understand and treat the full patient, which is what makes delivering health care so rewarding in the first place.
We’re learning if they have mental health needs, we must address those alongside their high blood pressure. We’re uncovering if they feel isolated and need to be connected to a community organization that will give them social support. These conversations lead to a deeper, more productive relationship with patients, and that positively impacts their outcomes.
As we work together, as a value-based care team, to resolve outside factors impacting our patients’ health, clinicians also experience less burnout. We have a clear path ahead, with the support and resources we need to treat our patients, and it’s encouraging to make a meaningful difference in their lives.
Breaking the cycle
In the early years of practicing medicine, there were many days where I took patient problems home with me because I didn’t have anywhere else to go with them. I’d hear and see their challenges, but I couldn’t effect change by myself.
It was hard to see my patients suffer with health inequities that were inevitably affecting their care plan. It was a vicious cycle. With the care delivery transformation made possible through value-based care models, we’re finally able to acquire the information and resources we need to break through that cycle. However, we can’t do this alone.
We have to continually refine our intervention strategies and processes and align with the right health care and community leaders to create the most impact. There’s power in seeing patients from their perspective and understanding what’s happening in their world.
More than understanding what their blood pressures have been or what their sugars have been, it is about understanding the root cause of their health challenges. And now we have the tools to do something about the very real struggles they’re facing.