Addressing Social Factors in Your Patients’ Health
By Jennifer Larson, contributor
If you’ve ever cared for a patient who skipped important follow-up visits because he didn’t have reliable transportation, or you’ve had a patient who didn’t take her medications because she couldn’t always afford to fill them and still buy groceries, you’re aware of the impact that certain social factors can have on a person’s health.
And these social determinants are not a small factor.
A January 2013 paper from the Los Angeles County Department of Public Health noted that a population’s health is shaped 40 percent by social and economic factors. “The social and economic factors are not only the largest single predictor or driver of health outcomes, but also strongly influence health behaviors, the second greatest contributor to health and longevity,” wrote the authors of “Social Determinants of Health: How Social and Economic Factors Affect Health.”
It’s very important to be able to identify important social needs that a patient might have, said Anthony Ridley, LVN, case management supervisor at AltaMed Health Services.
“Patients with a poor social network suffer from isolation and disconnection,” he said.
This disconnection can impede their progress and ability to heal and, ultimately, their ability to live a healthier life.
“Patients are so vulnerable around transitions of care, and if you don’t do a good job, they will be back in the hospital,” said Katie Hartley, director of advanced illness management for St. Charles Health System in Bend, Ore. And returning to the hospital is situation that no one wants, particularly in this era of penalties for hospital readmissions.
Gibson noted the risks of downplaying social determinants’ impact. “A lot of the things that they’re trying to do to make the patient healthier are going to be futile,” she said. “It doesn’t do any good to write a patient a prescription if they don’t have the money to fill that prescription. Or write them a referral to send them to a specialist if they don’t have transportation to get to the specialist.”
According to the Centers for Disease Control and Prevention (CDC), social determinants of health must be addressed to be able to give people the opportunity to reach their full health potential, often called “health equity,” without being disadvantaged.
Newer care models consider social factors
Social factors that affect a person’s health aren’t always easily identified. But with many newer models of care, more attention has been placed on identifying social factors that might be at work and finding resources that address them.
The patient-centered medical home (PCMH) model that you might come across in some assignments, for instance, stresses the importance of coordinating care for patients.
In these types of models, practices and providers need to be deliberate about paying attention to social determinants’ impact on their patient population, said Amy Gibson, MS, RN, chief operating officer of the Patient-Centered Primary Care Collaborative.
“I think it’s important that somebody needs to be paying attention to it. It’s one of those things when, if it’s not somebody’s job, it’s nobody’s job,” she said. “It has to become a formal part of the patient assessment and their planning.”
The team approach of the PCMH model is suited to that model, she added, and nurses, with all the education and skills that are inherent to their profession, often play a major role. In fact, many care managers in primary care practices are nurses.
In the hospital setting, the team approach is also crucial.
Interdisciplinary collaboration is a key factor to successfully identifying and planning for a patient’s needs once he is discharged from the hospital. Sometimes the various roles do overlap, but everyone can play a role, said Hartley.
Everyone, including bedside nurses, can be on the lookout for red flags and pass that information on to the case managers and social workers, who can then incorporate the information into the patient’s discharge plan.
The PCMH model and its variations also involve connecting patients with resources beyond the clinic walls.
A 2011 white paper from the Agency for Healthcare Research and Quality (AHRQ) titled “Coordinating Care in the Medical Neighborhood” described it like this: “At its core, the PCMH model suggests that PCCs [primary care clinicians] should know about available resources for different patients’ needs and be able to make referrals, and then follow-up with patients to ensure that they access those services.”
The authors also noted, however, that the broad array of community agencies can make coordination “difficult.”
Ridley suggested that providers network with community organizations, as stronger ties between health care and community organizations ultimately benefit everyone. “Organizations can support nurses/care managers/care coordinators by sharing community resources such as Rainbow Directory [a social services referral guide in California] and 211 with these care continuum members,” he said, adding, “Individual cities and communities also have resources such as taxi vouchers that often go under-utilized.”
The need for connecting people with community services will likely increase as the population ages, said Leslie McGregor-Landerkin, BSN, M.Ed, director of integrated care delivery for Premier, Inc. Different organizations will structure it different ways, but the concept of the care manager is not likely go away.
“Each organization decides how it’s best implemented for their population,” she said.
What can the individual nurse do?
Nurses are encouraged to use their nursing skills to listen, observe and pick up on cues from patients that can be passed along to a care coordinator, social worker or other team members.
While it may be easier for permanent staff to become familiar with other team members and available community resources that can help patients, travel and temporary nurses have options, too. Hartley suggests that you ask your charge nurse about the discharge process and ask to see the discharge plan documents for patients.
“Read the notes, so you know what’s going on,” she said.
“Reach out to the organization’s care management department, or if they don’t have one, the social services department,” said McGregor-Landerkin. “Those are your experts.”
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