Social Determinants of Health: Centuries Old, But Newly Scrutinized

An interview with a subject matter expert sheds light on one of healthcare’s trendiest topics.

Editor’s Note: Ellen Fink-Samnick is a member of the RACmonitor editorial board and a permanent panelist on Monitor Mondays whose areas of expertise include the social determinants of health (SDoH). Chuck Buck recently conducted an online interview with her, and what follows are selected excerpts.  

Buck: Social determinants of health (SDoH) seem to be a much-discussed topic in healthcare these days. So, peeling away the hype, let’s begin at the beginning. When did the SDoH first enter the American healthcare lexicon? Can you trace the origins of this issue?

Fink-Samnick: The SDoH are not new, for they’ve been with us for centuries. Students of social welfare and public health studied the “worthy and the unworthy,” with some population always at risk of poverty, homelessness, unemployment, incarceration, and ultimately succumbing to illness, if not death. Sir Michael Marmot became an early voice for the people and communities impacted most by these dynamics. A British epidemiologist and Chair of the Commission on SDoH for the World Health Organization (WHO), Sir Marmot conducted seminal research on the topic, forging a direct link between health and social circumstances. His work emphasized how the longer people lived amid stressful economic and social situations, the greater the impact would be on their health and health outcomes.

Research continued, and ultimately, the SDoH crossed the radar of every major surveillance entity, from the WHO to the Centers for Disease Control and Prevention (CDC), with attention also being given by the Robert Wood Johnson Foundation. Anyone working on the front lines of health and behavioral healthcare has been a firsthand witness to those persons and communities most at risk.

Then came Schroeder’s seminal study in 2007, which shocked the industry, stating that clinical care is responsible for a surprisingly limited percentage of deaths, as few as 10 percent of the total. Another 30 percent were associated with individual genetics and genetic predisposition to illness. However, the largest percentage (40 percent) was due to individual behavioral factors such as treatment adherence or acceptance of the need for treatment, with the remaining 20 percent related to social and environmental factors. A whopping 60 percent were due to non-clinical factors alone.

The data has come fast and furious ever since, cutting across race, ethnic, socioeconomic, and gender lines, and being explored in relation to disease states (e.g. diabetes, asthma, women’s’ health, obesity, cardiovascular disease, renal disease, mental health, etc.). New numbers from earlier this year show the SDoH’s role in healthcare now at as high as 80 percent of all cases from the combined factors of socio-economic issues, healthcare access, health behavior, and physical environment.

Buck: The SDoH cuts to the core of patient health, the disparity in patient care, and access to that care: Why is this suddenly such a popular topic and so important to you?

Fink-Samnick: My interest pre-dates the industry obsession with hospital readmissions that began around 2012, and the millions of dollars in penalties. Recent numbers reveal that over 50 percent of readmissions occur due to the SDoH alone. Working in hospitals and healthcare systems for my entire career, there were always patients who needed more than could be provided, whether limited by insurance or the lack thereof, social circumstances, or other related factors such as family support. These persons were compromised by their ability to access and receive care, which translated to recurrent visits to the local emergency department, lending the nickname of “frequent flyers.” Length of stay was greater for these persons because they had no place to go, or no facility that would accept them. They were easily and frequently labeled as “non-compliant,” as if they were petulant children who wouldn’t do their chores or homework, as opposed to persons challenged by their life circumstances and limited options, most usually out of their control.

It was ironic that when I asked Dr. Ronald Hirsch to write the foreword for my book on the SDoH, he and I both recalled our early work on the front lines of the AIDS epidemic, and the challenges faced by people across the U.S and abroad. Along with the stigma that accompanied this virus, services and resources were frightfully scarce. We both worked in areas struck by the highest concentration of infection, in particular, metropolitan areas: Ron in Los Angeles and Chicago, and I in New York City’s boroughs, primarily Brooklyn and Queens. Many of the regions I worked in were already viewed as home to the most vulnerable populations, with heavy concentrations of intergenerational poverty, unemployment, family violence, substance use, and working poor. There were elderly who refused to leave the homes they knew for decades, despite the prevalence of crime and violence in the surrounding community. Access to care was a challenge at best, with frequent family abandonment. These communities were SDoH ground zero, and I was committed to doing as much as possible to enhance their human condition. It was the focus I was raised on, as a clinical social worker.

I became involved in community coalitions to look at ways to enhance care for these populations. The interprofessional team I worked with was as committed, which further amped up my drive to address care gaps. I co-authored a submission for one of the initial rounds of Ryan White grants, winning dollars to expand the Queens Hospital Center’s Outpatient AIDS/HIV clinic. My commitment to address the human condition for all consumers of health and behavioral health services has only gotten stronger.

Buck: What will make a meaningful difference in how the SDoH are addressed?

Fink-Samnick: I’m a longtime believer in community grassroots efforts; those have addressed gaps in care for centuries. Many of the current initiatives have been fueled by partnerships between community programs and social service agencies, with hospitals and health systems getting involved. What we are seeing now reminds me of those early Ryan White funding efforts: so many agencies facilitated the development of community coalitions to take care of their own, like the one I chaired in Southeast Queens and Jamaica, New York City. It’s an admirable effort to provide a person without stable housing an apartment or a meal; however, far more support is required to assure that the person stays in that better physical and emotional place for the long term.

I love to see healthcare systems investing in and restoring abandoned buildings to create housing units. Real winners from my perspective are Portland, Maine’s Housing is Health Program, the Better Health Through Housing Collaborative’ between University of Illinois Hospital and Health System, and Montefiore Medical System’s Housing at Risk Alert System’. All forged relationships with existing facility and community programs and resources. Persons at housing risk are identified, given some type of housing (short- or longer-term), with vital social service intervention to manage holistic care needs. The programs have reaped financial gains and high returns on investment for the involved organizations. However, more importantly, they have enhanced the human condition tenfold for individuals and families: the most valuable and successful outcome.

I’m also a big fan of a number of Medicaid managed care plans that have stepped up to focus services across the SDoH domains, including expanded case management programming for:

• Education: early childhood development, high school graduation, or GED completion, higher education, and enhancement of language and literacy skills.
• Health and healthcare: improving health literacy with self-management goals and supports, access to integrated primary care, substance abuse treatment, and emphasis on trauma-informed care.
• Neighborhood and recreational environments: access to healthy food, quality housing, and community collaborations to promote safe environmental conditions.
• Social and community context: civic participation, identifying loneliness, promoting job training.
• Economic stability: food delivery programs, housing, and utility reimbursement.

Buck: You are a professional case manager and were recently involved in producing the Case Management Society of America (CMSA) hospital case management white paper. What do you see as case management’s role in healthcare?

Fink-Samnick: Too often case managers are not used to their full potential, as in, emphasizing claims or utilization management only. In these stressful times, hospitals and health systems too often view case management as synonymous with care coordination and discharge planning: that’s a problem in the making. The focus must be on using the whole scope and potential of the professional case management role. That’s how successful handoffs and transitions, and reduced lengths of stay and readmissions, really happen.

Professional case management workforces include savvy, proactive, credentialed practitioners from across the health and human services spectrum: medicine, nursing, occupational/physical/speech therapy, pharmacy, respiratory therapy, and social work. They are a critical part of a health system’s armada, with a full scope of competencies that foster their ability to identify and intervene with clients facing challenges associated with the SDoH. The power of their expertise is massive:

• Client interviewing and clinical assessment;
• Interventions to address treatment non-adherence, family dynamics, and client engagement;
• Knowledge of community resources and linkage to promote effective discharge planning processes;
• Facilitation of necessary interprofessional communication to leverage care coordination;
• Understanding of the fiscal focus of care, revenue management, and often diagnostic coding; and
• Meaningful outcomes management.

These are all essential skills to use with any population, but especially those facing the SDoH.

Buck: There are a number of publications on the SDoH being released, from articles to white papers and books. What makes for a solid resource for the industry?

Fink-Samnick: There have been many publications lately, all well-intended. I’m such a writer, so of course, I expect others to be as well. However, I also know better. I never write something just for the sake of writing it, and I try not to read things that present this way. Here are a few items I look for or make sure to include in my own work so that it has greater appeal to others:

• The SDoH has become a behemoth, so partialize efforts and information:
  • There has been a fair amount of repetition in general reports, as in, providing a to-do list of SDoH priorities that have been outlined in five reports prior. For example, we know more funding is needed, so provide sources to access what is available. We know proactive assessment is needed, so offer tools or take time to develop new ones; that was one of the publisher’s stipulations for me when I wrote my recent book.
  • The industry is hungry for guidance and direction, so offer strategic solutions that provide thorough action plans for implementation.
  • Everyone wants current resources for their populations. Those publications that include a robust and current resource listing rock!
• Consider a unique perspective. I enjoy reading as well as developing and providing resources that provide innovative information: ones that I wouldn’t find anywhere else.
• Finally, I look for reports that are organized and provide clear evidence and current data that I can directly apply to my scope. The ability to leverage the information to unique practice settings and populations is a win.

Buck: What is your SDoH priority list?

Fink-Samnick: My top three are the following:

1. Reimbursement: We’ve said for years that where the Centers for Medicare & Medicaid Services (CMS) goes, other third-party payors follow suit. With the SDoH, CMS is far behind a number of payors, such as UnitedHealthcare, Blue Cross Blue Shield, and Cigna. There must be proper reimbursement through CMS to start, as in the expansion of the ICD-10-CM Z codes to incorporate the recommendations posed by the American Medical Association (AMA), UnitedHealthcare, and National Committee for Quality Assurance (NCQA) for:
   • Caregiver hardship;
   • Food insecurity;
   • Housing;
   • Transportation challenges;
   • Payment of utilities; and
   • Medications.

Continued reimbursement advancement must continue across all payors, and not simply be a flash in the pan.

2. Real management of the costs of care: The SDoH has put care costs on everyone’s radar: payment for non-clinical services, prevention, and wellness for chronic illness, and reducing unnecessary emergency department visits, with national health expenditures for 2017 at $3.5 trillion. Timed with the industry emphasis on value-based care, there must be a continued acknowledgment that the value versus volume challenge will be with the industry long-term.

3. Education about SDoH populations: There is too much lack of understanding, if not bias, across the industry about who the faces of the SDoH are. We need to begin this education earlier on, as in, higher education and continue it through professional development. The term SDoH does not simply refer to populations served by safety-net facilities or federally qualified health centers. It is not simply Medicaid, unemployed, poor patients who live on the “other side of the tracks,” or those “non-compliant” clients.

The face of the SDoH has expanded to countless other populations, with the data reflecting challenges for:

• Homeless veterans
• Woman impacted by domestic violence and gender discrimination
• Victims of trauma
• Residents of rural regions
• People who are socially isolated
• Children and adults living with disabilities
• Victims of natural and manmade disasters
• Members of the LGBTQ community who face societal stigma, rejection by healthcare providers, and abandonment
• People facing sudden shifts in financial status, loss of income from business closures and government shutdowns, and older adults who lose pensions 
• Those living with mental illness 

Also of pivotal importance on my priority list are:

• Appropriate professional case management staffing to allow for more than a “treat and street” approach for patients, but one that allows for true assessment and intervention.
• Use of grant funding to build initiatives and programs.
• Continued community coalitions and grassroots efforts.
• Addressing the Social Determinants of Mental Health, which have been greatly overlooked.
• Focus on behavioral health integration that attends to the co-occurrence of health and behavioral health issues.
• True attention to Wholistic Case Management^TM: an approach that allows for attention to the whole person’s care, as opposed to leaving holes in care.
• Continued development and expansion of interprofessional teams across every practice setting, and the transitions of care. The blending of unique disciplines to address the complex needs of those facing, if not at risk for, elements of the SDoH can become a powerful way to achieve successful outcomes for all stakeholders.

Given how fluid attention to the SDoH is, I’m sure there are a few other priorities that I’ll think of, but that should tide our readers over for now.

Programming Note:

Listen to Ellen Fink-Samnick live every Monday on Monitor Monday, 10-10:30 a.m. EST.