As she tended to her patients at Seattle’s Harborview Medical Center and later at the North Valley First Choice Community Health Center in New Mexico, Laura Gottlieb, MD, MPH, knew that she needed to do more to truly support their health than offer a diagnosis, bandage wounds and write prescriptions.
“I became really frustrated with trying to make people well and then sending them right back to the conditions that made them sick in the first place,” said Gottlieb, a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar (2009-2011) who is now an assistant professor of family and community medicine at the University of California, San Francisco. “I just didn’t have the tools in my medical bag that my patients needed, like nutritious food, housing or employment.”
Working primarily with Somali refugees, Mexican and Central American immigrants and other underserved populations, Gottlieb was also disturbed by the lack of social support staff at many health care organizations. Large hospitals, such as Harborview, often had only one social worker for 8,000 to 10,000 patients and most community health centers had no social workers at all.
A New Social Determinants Resource for Providers
Inspired and encouraged by the impact of programs that address the social determinants of health, Gottlieb partnered with Rishi Manchanda, MD, MPH, and Ricky Choi, MD, MPH, to found HealthBegins an organization based on the premise that “smart medicine starts upstream.”
“We created HealthBegins to help providers learn more about the health effects of social factors and how to address them,” Gottlieb explained. The site includes educational modules on major social determinants, blogs, and tools designed to help health care professionals screen for and resolve health-related social problems.
Using the principles behind HealthBegins, Gottlieb and her co-authors, including Megan Sandel, MD, MPH, medical director of the National Center for Medical Legal-Partnership, wrote an essay outlining key methods of addressing the social determinants. Nancy Adler, PhD, co-director of the RWJF Health & Society Scholars program, also contributed to the essay.
Three Tiers of Intervention
The article “Collecting and Applying Data on Social Determinants of Health in Health Care Settings,” published in JAMA Internal Medicine’s June 10 issue, is an in-depth analysis of barriers and opportunities for providers, health care institutions and communities to address health-related social needs.
Gottlieb explained the impetus behind the article and her broader work through HealthBegins. “Even as a medical student, I was interested in the social determinants of health, but I was pushed to focus on the population level. Later in my career, when I became a Health & Society Scholar, I met people from all disciplines who were working on disparities, but again, mostly at the population level.”
Citing recent literature reporting that only 10 percent to 20 percent of premature mortality can be attributed to access to quality health care, Gottlieb added, “currently, what we address in clinical settings is a very small part of protecting health. Factors such as where people live, whether they finish school, and how much money they earn play a much larger role. We could do more inside our clinical settings to address these upstream factors.”
Gottlieb and her co-authors argue that electronic and other medical records should fully reflect a patient’s social circumstances. They then propose a framework for health care organizations to address these social circumstances at three levels.
- Direct Patient Assistance: Research shows that disease risk calculators, such as those for heart disease and mental health, are more accurate when they include information on social factors like poverty and education. Providers might also act on social data by referring patients to community resources, bridging health care settings with public health or social services. Patients with housing problems, food insecurity or other issues could be connected with helpful programs such as the National Center for Medical-Legal Partnerships or Heath Leads. Both programs are recipients of RWJF funding.
- Interventions for Employee and Patient Populations: Health care organizations can address the social determinants of health in the patient and employee populations they serve as well. Potential interventions might include an on-site farmer’s market; physical activity subsidies for employees; and living wages for all employees.
- Community-Based Policy Changes: Data on the social determinants of health collected at a local level should be used by health care organizations to influence community policy and bring about changes that are protective of health. Examples of activities might include: lobbying for increased cigarette taxes or advocating for healthier neighborhood design.
Going forward, Gottlieb noted the need for an improved evidence base with better outcomes analysis for the social determinants. “We need more effective measures to understand the impact of income, education and related issues on health. We also need to develop solid economic arguments that will help medical insurance companies recognize the important role that supportive, non-medical services play in sustaining health. Last, we need consistent and ongoing financial support for organizations that provide enabling social services.”
Gottlieb also calls for a health care work environment in which social workers, nurses, physicians, medical assistants and other professionals who contribute to patient care and support are allowed to operate at their degree level. “There’s a great deal of confusion in the health care sector right now about how to support and staff projects that address health-related issues that rest outside of the traditional scope of clinical care,” she noted. “We need to develop a comprehensive ecosystem that addresses the social determinants of health.”