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Social determinants of health (SDOH) have been shown to have a significant impact on patient outcomes. Many studies including the Centers for Medicare and Medicaid Services (CMS) have identified key SDOH issues including access to food, housing, utilities, transportation, and interpersonal violence. However, there is not much information on the steps taken to address these challenges for patients. The goal of this study was to gain insight on strategies to limit barriers to health care by evaluating the characteristics of different case management modalities used to address the social needs of patients. The authors of the study used web searches and the National Survey of Healthcare Organizations and Systems (NSHOS) to select sites with active social care programs and that were diverse in terms of ownership, structure, geographic location, and urbanicity. The authors conducted interviews with various leaders and staff members to determine the different characteristics of each social care program.
In total, this qualitative study included twenty-eight primary care centered organizations with a broad geographic representation across the United States of America. Social care models were separated into “embedded” and “standalone” categories based on whether social needs were addressed in the context of clinical care or if social needs were addressed independent of clinical activities. “Embedded” models typically involved the use of in-house staffing when taking care of patients with preexisting chronic illnesses; while “standalone” models involved community health workers and/or social workers to address social needs regardless of clinical conditions. All programs offered referrals to CBOs with varied levels of assistance offered. Fourteen of the thirty-three organizations acted as patient “liaisons”, assisting patients with paperwork, and navigating the CBO process. The range of follow-up with the patients included providing a list of CBOs, home visits, attending patient appointments, and daily phone calls. Organizations also differed in whether or not they addressed “acute” or “chronic” assistance. “Acute” assistance was defined as one-time solutions such as transportation to an appointment, while “chronic” assistance meant investigating long-term barriers to follow-up. Through the interviews, the researchers found that each organization also had operational challenges that were divided into four major categories: community-based organization (CBO) engagement, staff hesitancy, patient involvement, and sustainability. The authors of the study then proposed several solutions to address these operational challenges.
The strengths of this study include its qualitative methods, diversity, and the solutions offered to overcome the challenges found. Qualitative methods allow the context that is needed to address social needs and interpret the data collected. We are able to better evaluate what results actually mean and how they fit within our target population. The disadvantages to qualitative study methods are the need for long-term collection and the effort needed for data analysis. Aiming for diversity, the authors searched for different health care settings and structures, geography, and size. Through web searches for programs that address social determinants of health and the use of NSHOS, they included “6 single-site primary care organizations, 9 multi-site organizations, 12 health systems, and 1 contracting organization that functioned similarly to a health system”. This is one of the study’s strengths because it gives many different examples and levels of involvement that can be used and replicated by other organizations and communities that may be similar. Identifying strategies to address the challenges that this study found was essential because the goal of this paper was to look at the next steps that need to be taken to overcome social barriers in health care.
The limitations of this study were discussed by the group. “Urbanicity” as a selection criterion is not clearly defined from this paper. The impact of urban versus rural populations is not explored to the extent that we thought appropriate. It is well known that rural communities vary drastically; there is more distance, less transportation, different exposures, and risks with rural communities in comparison. Urban communities face their own unique disparities and challenges that limit access to healthcare. Different strategies and models may work better for a certain type of community than another.
As a group, we discussed several ways to expand upon the topics presented in this article. With the variety of health care settings and levels of service provided, it would be useful to know if there was a difference in chronic disease outcomes with embedded models versus the standalone model. This could also be evaluated for urban settings versus rural. This study mentions the need for patient perspective but does not include that in their interviews. This would be useful information to see what the patients think of the services being provided, the level of involvement, and their own preferences for care and outside resources. How do patients’ want their social care to be delivered? What is easy for them? We must encourage this relationship with the patient and respect their autonomy. With patient interviews, we could identify any gaps and address them to improve the programs being implemented. This extends to staff and volunteer workers. Engaging the CBOs early on in development and continued upkeep of a good working relationship seems to be key with sustainability and successful patient follow through.
As future clinicians, this study highlights the importance of relationship maintenance with community resources, staff members, and patients. Social determinants of health have prompted a change in perspective from symptom only treatment to contextual and holistic treatment of individual patient situations. Patients may be uncomfortable talking about the social aspects impacting them with their physician. Depending on the individual, it can be better to implement the models discussed in this journal to get a more thorough evaluation and provide the appropriate time needed to give them options for care. The best answers and strategies depend on the individual and it cannot be a one size fits all approach. Community-based organizations have limited funding and often have to close services; therefore, we must keep up to date on the resources available for our patients. Asset mapping should be checked frequently to avoid delays in care and positive outcomes.