COVID-19 magnifies impact of SDOH on U.S. healthcare system
"We are learning social determinants of health and health equity are inextricably linked, and that they represent a crisis today that runs alongside the COVID-19 pandemic. So if there's one useful thing to come out of the pandemic, it’s that it has highlighted the urgent issues that need to be addressed."
— Jenifer Leaf Jaeger, MD, MPH
The critical importance of addressing social determinants of health (SDOH) to help reduce disparities in both health and healthcare was a central theme that Jenifer Leaf Jaeger, senior medical director for HealthEC, explored in a recent conversation with hfm. Here, we provide an excerpt of that conversation.
Q: Why has the issue of tracking and addressing SDOH become so much more important today?
Jaeger: It’s pretty clear that COVID-19 disproportionally impacts persons with underlying chronic diseases such as congestive heart failure or coronary artery disease, COPD, diabetes and obesity, in addition to advanced age. But what we have also witnessed early in the pandemic within the U.S. is that Black Americans are at a much higher risk of severe infection and death compared to whites. And this appears to be because they are at increased risk for these underlying chronic conditions. We see risk tracking along poor health overall for people in poverty, and that is a reflection of SDOH.
Q: What falls under that heading of SDOH?
Jaeger: Many people will tell you SDOH is new in the conversation. And it's really not. In 1998, the World Health Organization [WHO] published a paper, Social determinants of health: The solid facts, and they addressed the fact that there are issues beyond healthcare or one’s genetics that actually impact health. And 20 some-odd years later, we have made, I would say, a minuscule attempt at being able to address this issue. WHO defines social determinants as, “the conditions into which people are born, grow, live, work, and age?” And these circumstances are shaped, WHO says, by the distribution of money, power and resources at the global national and local levels. That summarizes a lot, because it encompasses the political, socioeconomic, cultural, and physical environment.
Consider medical care, including both quality and access. It's estimated that medical care only accounts for about 10% to 20% of the modifiable contributors to health outcomes, meaning length and quality of life for an entire population.
As a physician, I got into this field because I wanted to improve the health and well-being of individuals, and my impact, although certainly important, really is a small aspect of it. We talk about behaviors such as smoking, diet, exercise, alcohol or substance use, and that accounts for another 30% of what shapes a person’s health and outcomes.
But the social or economic factors, which constitute SDOH, account for roughly half of the impact on health and well-being. So you're looking at education and employment, and that's different from income. You have high-risk areas, where people are working where there are toxic substances. And then there’s family and social support. For instance, we know senior isolation is a major risk factor during COVID. And then we also look at the physical or built environment, including water and air quality, housing and transportation, and that’s about 10% of what shapes health and outcomes.
So all told, SDOH account for nearly 80% of an individual’s health and well-being. So that's why we need to address them. And neither healthcare nor public health can do it alone. To really effect change on chronic disease management, and SDOH, we all need to work in tandem: Medical care must go hand in hand with attention to the social determinants to really have an impact.
Q: What can hospitals and health systems do to address this problem? Can you give an example?
Jaeger: Just look at senior isolation. We know it’s a health risk that affects about a quarter of seniors over the age of 65. And we know isolation is a risk factor for poor aging outcomes, development of cognitive decline, even Alzheimer's disease and actually contributes to worsening medical conditions and even death. Recent statistics show $6.7 billion in additional healthcare costs annually due to social isolation of seniors. And COVID-19 has only exacerbated the impact. Since our seniors are an at-risk population, to protect them, we've isolated them to an even greater extent and said families can’t come to visit. And they are now also told, “If you don't need to go to the hospital, don't, because of risk of exposure.”
The problem is, many seniors use going to the doctor as a social event. They're chatting with the people in the waiting room. They're chatting with the person who checks them in and the nurses, and they talk about their kids and show their photos. So there's a lot more to doctor visits than just medical care.
But what we're seeing now with COVID-19 is that we have isolated these individuals.
One of the ways that we can start to address this issue is by using population health management and health IT to perform telehealth.
So how do we identify all the individuals over the age 65 who are at particular risk and then help them access telehealth services? That requires risk stratification, which involves data analytics to identify who is at risk. That requires being able to pull in all the data, including ZIP codes, to identify where they are, so we can then reach out to them and do SDOH assessments of their risk of food insecurity, whether they have economic issues and are unable to pay for their health, or whether they have any problems with access to their medications. These are just a few of the assessments you can do.
You also need to assess any medical issues they have had over the past year that have been deferred but can no longer be deferred. So for example, oncology services, with staging, biopsies and MRIs and various other procedures are not emergent, unlike a heart attack or a car accident, but they're not elective either. There’s a whole population of chronic diseases that needed to be managed while folks were in isolation.
Q: How do you reach out to people who have technological challenges and are unable to access telehealth?
Jaeger: Calling them is at the lowest level of technology, certainly. Even if they're not sophisticated in telehealth and they don't know how to use their computer, you can call them on the telephone and speak to them, identify what their issues are and then seamlessly refer them to other areas — dental or medical health, behavioral health, or community resources — to address SDOH.
One way to address these issues is for community-based organizations to establish programs for seniors to learn how to use the internet and engage with telehealth. While still maintaining appropriate distancing, seniors would also be provided social interaction, could be given masks and information regarding how to keep themselves safe, and have their needs regarding access to food, medication refills, etc. addressed. I don't know that anybody has done this work, but I would say that it would be cheaper for health insurance companies to actually provide a laptop to every individual who doesn't have one and pay for the training to avoid unnecessary emergency room, hospital and ICU visits and a worsening of chronic conditions. Treating these avoidable medical issues is probably a lot more expensive than laptops. I would love the opportunity to crunch some numbers and provide some strong data to various payers, including Medicaid and Medicare.
I would imagine that there would be both cost savings and improved health care. And since CMS has expanded access to telehealth services for Medicare beneficiaries, seniors can receive a wider range of medical services without travelling to their providers.
The advantages of investing in telehealth for this purpose are huge. Being able to have a face-to-face meeting through the use of a computer with an elder allows the provider or care manager to get a peek into their environment. Are they dressed and showered? Do they you look like they haven't gotten out of bed in three days? Do they require social support?
Then you need the seamless coordination that is the whole point of population health management — being able to pull in clinical data and seamlessly connect individuals to needed community resources. That’s the kind of immediate real-time evaluation and response I think is critical now.
Q: How can hospitals or health systems begin to build the networks necessary to make this work?
Jaeger: There are a number of different programs that hospitals can get into. Boston Medical Center, for example, has gotten involved in developing housing projects for their at-risk and vulnerable population that’s at risk for homelessness. So they're actually in the business of building homes, and that's not what you would normally think of as the mandate for a hospital. That level of involvement is not available to a small hospital, of course. But any hospital or clinic can join forces with the community programs that already exist to gain more awareness of the SDOH-driven needs in the community and begin to address them.
Remember, though: If you don't even ask the question, you can’t know the answer. There's an approach called the Hunger Vital Sign, which came out of Children's Health Watch and Boston Children's Hospital that addresses this point. It's two questions that correlate with a high likelihood of food insecurity within the past month. But most pediatricians or internists don't take time to ask the necessary questions, such as, “Do you think you might have to go without something in order to feed your family this week?” If we would make a point of asking that question, we could start to identify where those issues are, and that would enable us to work with the local food bank.
Prince George's County Health Department in Maryland offers a great example of using SDOH in assessments and analytics to risk stratify and then address the issues they have found working with community partners. They use analytics and population health management to identify the 10% of the population that represents 80% of hospital readmissions and non-urgent emergency department visits. Working with their community and having community health workers embedded within the health department to do contact and outreach, perform assessments and then make referrals, they have been able to reduce hospital utilization by 22%, including emergency room observation and inpatients, and reduce costs by 17% to achieve a nearly half a million dollars of savings within six months. They were able to improve health outcomes and reduce costs simply by addressing SDOH. It's really powerful.
Q: How can organizations begin to address SDOH?
Jaeger: It starts with communication and education regarding the importance of addressing SDOH to improve health and well-being. If you can then demonstrate cost savings, so it's sustainable, that's even better.
Tying it back to COVID, it's not surprising that there’s a growing awareness of issues of health disparities and the Black Lives Matter movement —which is so much more than a movement. It’s important to stress that the virus doesn't know what color you are or what gender, sexual orientation or nationality you are. But it does recognize vulnerability. You can look at the data for seasonal influenza and any number of chronic diseases, and you can see these disparities.
So we need to raise people’s awareness of these issues. It is an idea whose time has come.