“Social Determinants of Health” Impact Individuals, Communities More Than Even Medical Teams May Realize
“49-year-old male with hypertension, diabetes, and chronic kidney disease. Patient has been non-compliant with health recommendations and prescribed medications.”
The word “non-compliant” (failing to act in accordance with a wish or command), when used in a medical context, sounds paternalistic and inappropriately simplifies the clinical situation. It feels as if the medical community is placing patients in boxes, labeling them rather than looking at the underlying reasons why someone doesn’t follow a treatment plan.
Keep in mind, for some patients, just making and keeping a doctor’s appointment presents some or all of these challenges:
- Wait months for the visit
- Get time off from work
- Find childcare
- Find transportation
- Have money for the copay
- Wait hours for the doctor
It can all cause an increase in blood pressure, after which the doctor may diagnose something difficult to understand and prescribe medication that, if you Google, has side effects ranging from hair loss to impotence to death. And the price of that medicine? Anywhere from $10 to more than $1,000.
As a healthcare community, we must understand that visiting a doctor, including following all instructions afterwards, can be especially daunting for those facing daily life challenges. We have to help providers and care teams identify patients that require assistance, stop labeling them with loaded terms, and connect them with the help they need.
All individuals, regardless of where they are treated, have some type of electronic health or medical record generated to provide a digital file of patient-related information. At Memorial Healthcare System, we’ve added tools to our patient’s medical records that identify those who may have a harder time keeping appointments or following a care plan.
Known as the “Social Determinants of Health,” it accounts for those who don’t have access to healthy, affordable food, stable housing, caregivers, childcare, transportation, and more (these challenges impact communities of color more than others, with its roots in structural and political determinants beyond the scope of this column). Nevertheless, it’s imperative for healthcare systems and providers to seek additional resources for those in need.
We now task staff with documenting in a patient’s records that person’s struggles with food insecurity, housing, transportation, etc. This “problem list,” combined with the patient’s active, chronic conditions, helps coordinate care across the healthcare continuum and between systems, enabling any clinician to get a complete picture at a glance.
Taking it a step further, providers are now alerted when a patient screens positive for a Social Determinants of Health, automatically adding it as a diagnosis on the problem list and alerting the care team the individual needs assistance. Medical staff now get annual reminders to re-evaluate these important measures of health outcomes.
As a physician leader, I’ve worked with IT to make our patient records more relevant and easier for providers to navigate. The changes ensure our teams know where gaps exist, making wellness visits and advanced care planning conversations more intuitive and effective. We’ve expanded telehealth and same-day visits to help patients get the care they need, when they need it.
Going back to our earlier example, imagine if that patient’s chart had a problem list that included: “hypertension, diabetes, kidney disease, food insecurity, housing insecurity, and caregiver fatigue.” Would care teams interact and communicate with that person differently? Would a surgeon view the scheduling of elective surgery and the post-op rehab/care the patient requires from a different perspective? Would it impact the team’s outreach after the visit? As importantly, would we be so quick to label patients as “non-compliant” if they aren’t able to follow all the instructions?
Having devoted my career to community medicine and as an advocate for the marginalized, my hope is the answers to those questions change the thinking and record-keeping processes of healthcare providers. It would improve the quality of care and make medical outcomes more equitable.