“You’re going to need a bigger boat” (Chief Martin Brody to Quint, captain of the Orca, Jaws, 1975).
It may be a little bit of a stretch to compare anything we do to the marauding great white shark in the movie Jaws, but just like the fictional town of Amity Island, we have a huge issue lurking out in the depths of our health community that our relatively tiny boat of clinical care will not be able to handle.
Social determinants of health is that issue. The World Health Organization defines social determinants of health as: “…the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life…” As payers transition us to more financial risk for the populations we manage, we will quickly realize how rapidly our tiny boat will be swamped by the massive scope of addressing social risk factors. Success in addressing the social needs of our patients is definitely going to require a bigger boat.
But first, let’s correct a misconception; not all social determinants are bad. We are all a product of our social determinants of health. Some social factors, like a safe place to live or a supportive family, provide beneficial effects to our health and longevity; while others, like crime or food insecurity, have detrimental effects. So our efforts around social determinants of health are more precisely about mitigating the effects of social risks; those conditions that are detrimental to health outcomes.
I think we’re finally convinced that social determinants are a thing because the term social determinants of health has become so ubiquitous in health care. Next, (and this is a tough step for clinicians) we have to accept what the research is telling us: social factors may be a much stronger determinant of health outcomes than the clinical care we provide. Then we have to find the time and the inclination to start asking potentially tough questions of our patients around social risks, like lack of resources to meet daily needs or lack of social support at home. To begin with, we don’t necessarily need to have these conversations with every patient, but our initial focus should at least be on those individuals we’ve classified as high needs.
And if we manage to ask the questions, what do we do with the answers? That’s where the bigger boat comes in. Our care teams need to grow to include community resources that can help us support the social needs of these patients. CMS has actually developed the Accountable Communities of Health model that seeks to address what they term as the “…critical gap between clinical care and community services.” Forming these accountable communities of health is not just about working within geographic boundaries; it is really about forming a community individualized around patients’ own social needs and then working within those community teams to maximize good health for our patients.