2019: The Year of Social Determinants of Health and Whole Person Care

The healthcare industry has been a champion of whole person care for decades, yet we seem no closer to a solution than we were in the early days of nurse advice lines and disease management programs.

In past decades, public and private healthcare organizations looked toward Maslow’s Hierarchy of Needs for answers. Healthcare reached out to underserved populations to help with and address basic needs, such as food, water and housing, and transportation in a quest to help individuals with severe health issues better manage chronic diseases. Maslow’s blueprint understood that if you don’t know where your next meal is coming from, there’s little chance you’ll be thinking about improving your health.

Today, the social determinants of health (SDoH) focus on many of the same concepts found in Maslow’s observations, but in more concrete terms. Described by the Centers for Disease Control and Prevention as unstable housing, low income, unsafe neighborhoods or substandard education, SDoH has the potential to negatively impact healthcare and patient satisfaction if left unresolved.

The easy part—thanks to artificial intelligence and algorithms—is identifying SDoH in patients. The hard part is acting on the information culled from the data. Often times, significant issues arise because there are few processes and limited cost-effective resources in place to make a change among patients, especially the underserved.

Parsing the Data

In the early days of disease management, government-run health plans, typically, provided details about those participants with chronic conditions to the organizations providing care. Nurses would then contact program participants and it was at that time Maslow’s concepts came into play. This information was collected in reverse, making the job of disease management extremely difficult. It wasn’t until contact was made that nurses learned of the many issues keeping patients from receiving care.

Thanks to technology that only in the last few years has matured, we now can gather this information concurrently and automatically from a variety of patient records, providing caregivers with the information necessary to address SDoH.

SDoH data, for example, many times is recorded in progress notes, admission notes, procedure notes, discharge summaries and consultation notes in an Electronic Medical Record (EMR). The challenge, naturally, is cost-effective and efficient extraction of this data.
To meet these goals, healthcare organizations must deploy artificial intelligence (AI) and a natural language processing (NLP) algorithm to identify SDoH factors for individuals on a very large scale. AI and NLP tools review existing clinical notes in the provider’s EMR to identify patients at risk for SDoH factors.  The solution doesn’t require any additional surveys, phone calls or clinical workflow steps.

To start the process it’s necessary to create an ontology for the NLP algorithm. The algorithm then compares the ontology’s list of words and phrases relating to SDoH to those found in clinical notes. The initial ontology should include common words and phrases for individual physicians and clinicians use to describe SDoH, such as “food insecurity” and “homeless.”

The algorithm’s accuracy will be improved by using SDoH terms standardized by the National Institutes of Health and included in the Unified Medical Language Library. One study shows an SDoH algorithm to have 88 percent accuracy. Accuracy increases as the ontology set grows: As the algorithm is exposed to more records, it continues to learn the terms most commonly related to SDoH and automatically refines its ontology.

The automated nature of AI and algorithms ensures physicians and clinicians continue to provide patient care. The information could be supplied to care coordinators, who work directly with patients to improve SDoH-related conditions with the objective of improving health outcomes.

Taking Action

Collecting and analyzing the data is only the first step. In many ways, it’s also the easiest. A host of complications arise once a plan is devised. The plan must be made actionable. It’s not valuable if you can’t do something with the information. How can organizations stay in business while continuing to help patients? That’s the big question to which there’s no answer at present. But something needs to be done if the healthcare industry and society-at-large want to make a dent in the challenges that keep people from receiving regular healthcare services and managing their health.

As providers take on more and more responsibility for whole-person care under value-based care programs, payers, caregivers and the healthcare industry will need to join to address SDoH holistically.

Like most things in life and business, eliminating, or at least diffusing many of the challenges caused by SDoH cost money. A solid demonstration and study of how eliminating or, at the very least, mitigating specific SDoH issues, in turn, improve health and creates ROI is necessary to move any program forward. The Robert Wood Johnson Foundation has created an exhaustive library of research, analysis and news reports highlighting the various ways that SDoH are or may be addressed in the community. Steady housing, good-paying jobs and safe neighborhoods are among the steps necessary to stabilize communities and underserved populations with the result being improved health and wellness.

While these ideals likely are necessary to achieve health and wellness in many populations, it will be difficult to make the improvements without the investment of significant amounts of time and money from a number of public and private sources. (Any programs or changes, however, must be balanced with the patient’s privacy and dignity. No matter how changes are made, it’s important to make sure organizations aren’t interfering in people’s lives. We don’t want to invade anyone’s privacy. At the end of the day, it’s the individual’s responsibility to improve her care. It can’t be forced on the individual.)

In the meantime, we can take small, effective steps to make positive changes. Social prescribing is one way we may be able to make progress with patients of all types. Social prescribing uses four specific areas that address SDoH and Maslow’s Hierarchy of needs:
  • physical health;
  • psychological well-being;
  • perceived social isolation; and
  • financial stressors.
So, rather than or in addition to prescribing medication, a caregiver may write out a prescription for a daily walk through the park, spending more time with loved ones or an art class. The patient participates in an activity that helps alleviate the challenges found in one of the four areas above. In addition to positive side-effects, many activities often have the benefit of being low- or no-cost. A study published in BMJ Open suggests positive results can be had when addressing these issues:

“Most participants experienced multi-morbidity combined with mental health problems, low self-confidence and social isolation. All were adversely affected physically, emotionally and socially by their health problems. Findings suggest that tackling complex and long-term health problems requires an extensive holistic approach not possible in routine primary care. This model of social prescribing, which takes into account physical and mental health, and social and economic issues, was successful for patients who engaged with the service. Future research on a larger scale is required to assess when and for whom social prescribing is clinically effective and cost-effective.”

As cited by these United Kingdom researchers, many questions remain when it comes to eliminating the challenges caused by SDoH. It’s unfair to saddle a single group or industry with full responsibility to make repairs. Rather, this is a broad issue that demands a far-reaching response from government agencies, non-profit organizations and private industry. While technology has the ability to identify those needing assistance, we must work together to create a solid set of processes, and develop deep resources and programs all the while understanding the ROI of improved healthcare and decreased treatment costs will be necessary for long-term success.
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