1. What’s the health care sector to do about social determinants of health?
I’m Laura Gottlieb and I work with Margo and Colleen in the Dept of FCM.
I am so glad to be able to spend time with you all tonight as part of National Primary Care Week.
I’m trained as a family physician and I still supervise residents at the Family Health Center at SFGH.
But I do two other things as part of my job.
I run a residency curriculum that aims to help residents develop skills that will help them integrate advocacy, community engagement, and leadership into their future careers.
And then I am primarily a researcher who studies what roles the health care sector can play in identifying and addressing patients’ SDH.
siren

2. Used with permission from Jack Maypole, MD
I’m going to start by asking a question of those of you who are here tonight: Raise your hand if you have ever felt like the care you offer your patients overlooks the social and economic realities of their lives. Like you could have done better by the patient or the family by learning about the social and economic challenges that they were facing?
You can put your hands down.
But I want you to know that I am raising my hand because I have felt that way in different practice settings serving low income patients in Massachusetts, in Washington State, in New Mexico, and over the last decade, here in California too.
This cartoon was basically me. Everywhere I have practiced medicine, I have felt like the tools in my medical toolbox weren’t quite the right ones for treating the low-income patients that I was seeing in clinic. I needed to figure out how to get my patients food and jobs instead of insulin and anti-depressants.
Used with permission from Jack Maypole, MD

3. In fact, it’s becoming increasingly well-accepted that health outcomes are shaped more by social context than by what we do in clinic. This should look familiar to you as medical students today, but you should know that this was not part of my medical school education, nor Colleen’s, nor Margo’s.
Now we have twenty years of scholarship showing that socioeconomic factors like poverty (and the health behaviors that are shaped by poverty) contribute more to premature mortality than medical care. In other words, poverty is an independent risk factor for death: men in the lowest income bracket will die 15 years earlier than men in the highest one. (

4. SDH
The problem is that even while we know that the science now shows upstream determinants shape health outcomes, that picture with the provider ignoring the patients’ social and economic circumstances hasn’t changed. We don’t ask about Social Needs; we don’t document Social Needs in our Charts; We don’t get paid for treating Social Needs.
In fact, SDH are kinda the elephant in the room. No one likes to talk about them because it’s still really unclear WHAT WE AS HEALTH CARE PROVIDERS CAN DO about them.
By Social determinants I mean a combination of social needs, like food, housing, as well as social detrmiannts, like race, country of origin, educational achievement.
So I thought I would take a few minutes and talk about how we’re trying to change that.

5. Discussion questions
What should the scope of health care activities be around social determinants of health?
Patient level
System level
Community level
What are key facilitators and barriers to health system engagement at each of those levels?

6. Health care sector activities to address SDH
Community work
targets SDH
First, health care systems can engage in community-level work. We can develop stronger partnerships with public health and other sectors to impact SOCIAL POLICIES and COMMUNITY CONDITIONS. We could hire locally; we could pay living wages; we could have greener hospitals. These aren’t just ideas. Gunderson Lutheran hospital in LaCrosse, Wisconsin, for example, buys 20% of all hospital food locally. Dignity Health here in SF provides below market rate loans to non-profit organizations that help to provide job training, affordable housing, and build wealth in underserved communities. In Baltimore, Bon Secours health system has purchased over 500 units of affordable housing and converted over 600 vacant lots into safe green spaces. UCSF is currently trying to develop their own strategy for doing this work, for being an anchor institution in the community.
The work that health care systems do to improve patients’ SDH does not need to end at the community level, though. There are also ways we can transform clinical care delivery to better complement those community-level activities.
Public health
Adapted from John Auerbach. Three buckets of prevention.
J Public Health Management Practice, 2016, 22(3), 215–218.

7. Clinical care informed
Health care sector activities to address SDH
Clinical care informed
by SDH
Community work
targets SDH
At the clinical care level, we as health care providers can also learn to ACCOMMODATE the social risk factors that interfere with medical treatment. I refer to the activities in this bucket as SDH-informed care.
Some of this is work that we do everyday in the safety net, though not always well or systematically. We bring interpreters into our clinics. We dose medications around work schedules or the availability of refrigeration. We give transportation vouchers, open evening or weekend clinics, and send out mobile vans. We also do things like adjust scoring on the Mini-Mental Status exam for patients who have low literacy or education levels. But we don’t always group those changes to care under “These are ways that I change my care for low income patients.”
And we don’t systematically screen for or track patients’ social and economic needs so that we can routinely make those changes to care.
Health care
Public health
Adapted from John Auerbach. Three buckets of prevention.
J Public Health Management Practice, 2016, 22(3), 215–218.

8. Clinical care informed
Health care sector activities to address SDH
Clinical care informed
by SDH
Clinical care targets
SDH
Community work
targets SDH
A third bucket of work leverages the clinical encounter to directly target patients’ social and economic hardships.
For instance, some health-care based initiatives provide employment programs in addition to providing free transportation vouchers; they provide refrigerators instead of change dosing schedules; connect patients with GED and English as a second language programs in addition to providing interpreter services; or provide food prescriptions alongside other medicines.
In the United Kingdom they refer to these activities, where you target the patients’ social needs as a part of health care delivery, as SOCIAL PRESCRIBING.
There are a lot of ways that hc providers can get involved around SDH.
Health care
Public health
Adapted from John Auerbach. Three buckets of prevention.
J Public Health Management Practice, 2016, 22(3), 215–218.

9. Social Need Identification within KP versus CMMI tools
KP Your Current Life Situation Survey (8 multi-part items)
CMMI Accountable Health Communities Survey (10 items)
Food insecurity (one question)
Food insecurity (two questions)
Housing situation, condition and safety
Housing situation, housing condition
Paying for utilities
Paying for medical needs
---
Transportation needs
Paying for child care
Paying debts
Interpersonal safety (4 questions)
ADL difficulty, difficulties “piling up”, check-off for 12 specific health and social needs
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
September 21, 2017

10. That big focus of my advocacy work is on building an evidence base to better understand how the health care sector can play a role in improving social context. I now direct run an initiative called the Social Interventions Research and Evaluation Network, or SIREN, which is a national research acceleration and translation initiative where we both catalyze and disseminate high quality research to advance our understanding of how to address social and economic risk factors in the context of health care delivery.
Just as one example, we’re now working with four major medical coding vocabularies that populate the back end of electronic health records to make sure there are codes available to you in your EHRs (wherever you may go) where you can document screening, diagnosis and referrals you make for patients with food insecurity, housing instability, lack of transportation or employment. Between two grant programs that we run, both SIREN and Evidence for Action, we also have funded over 2 Million dollars in research grants this year, and host an online evidence library to encourage those in practice to apply any evidence based practice that exists in this area.

11. | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Goals
To connect:
LINK social needs researchers and evaluators to share methods and findings.
IDENTIFY ongoing interventions to address social needs across KP regions.
COMMUNICATE the findings of these interventions.
APPLY advanced analytical tools to develop new knowledge.
REFINE social needs interventions for clinical and operational spread.
September 21, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

12. How to connect with SIREN
Website: sirenetwork.ucsf.edu LinkedIn: Social Interventions Research & Evaluation Network
Our website has a collection of resources that we think may be of value to you all. You can also sign up for our monthly newsletter from the website or you can us letting us know you’d like to sign up. The newsletter contains highlighted events, news items, recent additions to the evidence library, and more.
You can also connect with us via or one of our social media accounts.
siren

13. | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Steering Committee
Mateo Banegas, PhD, MPH, MS, KP Northwest
Jim Bellows, PhD, MPH, KP Care Management Institute
Rachel Gold, PhD, MPH, KP Northwest
Cara Lewis, PhD, KP Washington (formerly Group Health)
Julie Schmittdiel, PhD KP Northern California
Adam Sharp, MD, MS KP Southern California
John Steiner, MD, MPH KP Colorado (SONNET Director, )
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
September 21, 2017