By Teresa Schmidt, MS, OCHIN Research Analyst
This year, the annual meeting for the North American Primary Research Group (NAPCRG) was in Montreal, Quebec. Seven members of OCHIN’s research team were able to attend (photo by Les Enfants Terribles).
Social Determinants of Health
A large topic of interest at the conference was how to use information on Social Determinants of Health in the primary care setting. Social determinants of health (SDH) are the physical and social conditions in which we work, live, and play, and they have a large impact on our health, functioning, and quality of life.1 But despite a growing body of research on how important they are for health outcomes, it’s not necessarily obvious what primary care providers can or should do about them.
There were at least 32 presentations at the conference that described SDH in their abstracts, including one poster and three oral presentations by OCHIN researchers. OCHIN is fortunate that our ADVANCE data warehouse includes information on a great many community-level vital signs, based on the residential geography of nearly all of our 2 million active patients.2 In addition, we recently implemented a tool in OCHIN’s electronic health record (EHR) system that allows for community health centers to collect patient-reported information on several social determinants of health, including food insecurity, housing insecurity, financial resource strain, intimate partner violence, stress, and social isolation.3
Asking patients about their social determinants of health is seen by some clinicians as opening Pandora’s Box. Once a patient tells you they are they are homeless, don’t you have to do something about that? Helping patients to navigate a system of community resources and eligibility requirements can also take a lot of time and resources, even when you have staff who are dedicated to it. Moreover, some clinicians feel that the role of a clinic is to provide medical services and that addressing SDH should not be a priority. Yet for other clinicians, knowing about patients’ social determinants of health can be helpful for shaping their delivery of care.
To learn more about how this information can be used, OCHIN has been working with Kaiser’s Center for Health Research4 on a pilot study named ASSESS & DO,5 where three clinics collected SDH information from subsets of their patients. Initial findings presented at NAPCRG by Stuart Cowburn indicate that a high proportion of our patients face multiple social issues that could adversely affect their health. In fact, 97% of the patients screened during the study had a demonstrated need in at least one SDH domain.6
The study also revealed that referrals to community resources can be challenging to track. Clinics vary widely in how they document referrals to social services in the EHR, which can make it difficult for care teams to know where patients are being referred and whether those referrals result in patients getting the help they need.
In a series of interviews performed as part of the pilot study, Arwen Bunce from Kaiser’s Center for Health Research7 found that primary care providers responded in different ways when presented with SDH information. Some clinicians felt overwhelmed with all the extra information, given that there is already so much data that gets collected in the EHR, and that SDH-related issues are often difficult to address from a clinical standpoint. In contrast, other clinicians reported feeling relieved that the data is getting collected and became less concerned about their patients’ SDH needs. Several clinicians expressed confidence that someone else in the clinic, like a community health worker, will help patients to manage these important issues in their lives. In addition, some clinicians reported being able to adapt clinical care to account for SDH. One described finding out that his patient was using a cooler for a refrigerator, which made him realize he should stop prescribing that patient any medications that need refrigerated.
A critical caveat in this work is that not all clinics have staff that they can dedicate to SDH screening, community resource referrals and follow-through. When combined with the fact that so many patients reported having SDH needs, all three clinics in the pilot study ultimately had to limit SDH screening to a subset of patients in order to prevent clinic staff from being overwhelmed. This is quite understandable, yet when clinics have to prioritize who they collect the data from, there could be many patients who fall through the cracks.
Ultimately, there is still more work to be done in the development of workflows to learn about patients’ social determinants of health and to connect them with community resources that are available. We are proud to be developing EHR tools for patient data collection in our clinics, and we are honored to follow several clinics as they explore this new terrain. We hope our pilot study and our use of community-level data can help to guide future research and development of clinical best practices.
In addition to our posters and presentations, OCHIN had the opportunity to help facilitate two NAPCRG workshops on Social Determinants of Health. The first workshop, led by Laura Gottlieb, MD, MPH, director of the Social Interventions Research & Evaluation Network (SIREN), facilitated a dialogue among clinicians and primary care researchers on the priorities for future research on social determinants of health. During the workshop, Dr. Gottlieb presented the results of a recent Delphi survey to prioritize areas for research in the field and explained that research questions fell into the overarching categories of background, implementation, and effectiveness. Participants then broke into small groups to reflect on the findings, identify aspects that were surprising and/or areas they thought were missing from the prioritized list of topics, and think through ways that SIREN could help catalyze and disseminate future research on SDH in health care settings. One big idea that came out of the workshop was for SIREN to lead a sort of clearinghouse for ideas, where researchers and clinicians could compare notes on how different types of SDH interventions and measurements were being used, as well as anecdotes about their impact. OCHIN is excited to participate in this and expects that this kind of collaboration would be very useful in developing standard measures for social determinants of health and for developing successful models for implementing and evaluating the impact of SDH interventions.
The second SDH workshop that OCHIN helped to facilitate was led by Andrew Pinto, MD, MSc, a family medicine physician at St. Michael’s Hospital and assistant professor at University of Toronto, and focused on case studies where researchers utilized individual- and/or community-level data on SDH to inform clinical care, organizational change, and public health efforts. OCHIN Investigator Erika Cottrell presented details on OCHIN’s efforts to create EHR-based tools to facilitate SDH screening at the point of care and facilitate action to address identified needs. She also described other research projects at OCHIN, such as our Health Systems Demonstration project,8 that utilize community-level SDH variables that have been aggregated to the neighborhood or community level, to understand the impact of social factors on clinic-level measures of quality and utilization. This workshop also included presentations from Dr. Alex Krist of Virginia Commonwealth University, Dr. Daneille Hessler of University of California San Francisco, and Dr. Stephen Petterson of the Robert Graham Center. After the initial presentations, participants broke into small groups to discuss several key questions:
- Which individual- and community-level variables are most useful to inform action?
- What are the best methods for presenting SDH data to primary care teams?
- How can we measure the impact of integrating SDH data into primary care contexts?
OCHIN is proud of the opportunity to contribute to international efforts to tackle these important questions and to help shape future research on social determinants of health.
2 This is made possible through a partnership with Health Landscape, which does geomapping and linking to data from the American Communities Survey.
3 This is funded by an NIH grant project called ASSESS & DO
6 Note that clinics did not screen all patients.