Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? No.

Dr. Solberg cites important obstacles to taking on social determinants in health (SDH). However, there are a number of critical considerations for moving ahead with SDH in primary care despite these real challenges.

There is no doubt that burnout is high in primary care; today is a particularly challenging period for many primary care clinicians. These challenges underscore the need for a rapid shift towards team-based care so that tasks, including SDH screening and linkage, are better distributed among team members (as Dr. Kaufman notes).

Electronic technology offers promise for more efficient SDH screening and linkage. For example, self-administration of SDH screening using electronic devices is feasible for many (albeit not all) patients. Existing software, e.g. NowPow.com and Healthify.us.org, when appropriately populated can generate lists of local resources relevant to patients' priorities. Some of these SDH screening tools can be integrated into some electronic health records, minimizing duplication of data entry. Such systems could help reduce the burden on primary care while providing tangential, meaningful benefit to patients. Rather than postponing incorporation of SDH into primary care, we need to demand that electronic health record vendors create user-centered systems for efficient SDH screening and linkage into their next version. The IOM report entitled "Capturing Social and Behavioral Domains and Measures in Electronic Health Records" provides a useful starting place (see http://iom.nationalacademies.org/Activities/PublicHealth/SocialDeterminantsEHR.aspx)

Dr. Solberg correctly notes that we are in the midst of primary care transformation designed to achieve the triple aim, i.e. better population health, improved patient experience and lower costs. Arguably, addressing SDH is relevant to each of these aims. Moreover, as primary care practices join accountable care organizations that are responsible for the health of defined populations, SDH become even more relevant. New York State is incorporating SDH into its Medicaid Delivery System Reform Incentive Payment System Program (DSRIP). CMS is launching its own program to test and pay for addressing SDH. It makes sense to design integration of SDH into these evolving care delivery models now rather than trying to retrofit such integration later.

While we do not yet have compelling data from randomized controlled trials showing that such screening benefits patients, we have prima facia and common sense evidence. Some of the success of community health centers in improving population health is plausibly related to their historical focus on addressing patients' SDH. Jack Geiger, one of the founders of community health centers, actually wrote prescriptions for food for hungry patients paid for by the Delta Health Center in Mount Bayou, Mississippi. Dr. Geiger was probably not unique in responding to his patients' essential needs. What primary care clinician would not assist a patient who is homeless, hungry, or in need of heat, in accessing local resources? At some point, basic humanity trumps evidence; if we don't ask, we won't know who needs help.

Systematic collection of data regarding SDH serves other important purposes that have not been explicitly mentioned in any of the three papers on SDH. Patient SDH data when rolled up to the population level are critical to informing population health needs, to developing strategies for addressing health disparities, to establishing key community partnerships for addressing SDH, and potentially, to design of payment systems that align resources with level of population need. If want these our data on our patients, we need to develop feasible means for collecting them. If want the resources to address patients SDH, we need to document patient need. Once we have this infrastructure, we will be a much stronger position to conduct large scale, generalizable, but contextually relevant, research on impact.

Last, family medicine's origins are rooted in a biopsychosocial approach to the patient that includes SDH. Founding fathers such as Eugene Farley were passionate about this point. Today the AAFP acknowledges as much ( http://www.aafp.org/about/policies/all/social-determinants.html).

Dr. Solberg is partly correct. Taking on SDH during this period of rapid transformation will challenging. But challenging does not mean it is not right. Perhaps, doing what is right for the patients despite the inherent challenges and messiness will be the spark needed to help invigorate primary care by helping primary care clinicians find renewed purpose and meaning in their work. It may remind many of us why we choose primary care in the first place.

Competing interests: None declared