Image credit: Little Neighborhood by Rachel Elaine at Flickr

Social Determinants of Health, Part 3: Where Patients Live

by Dr. Randall Williams, MD

In the new world order of value-based care delivery, healthcare providers cannot afford to be unaware of, or choose to ignore, the major drivers of healthcare utilization that fall outside of “traditional” clinical care. These areas, called Social Determinants of Health (SDHs) include some natural and actionable categories like:

  • Timely, convenient and affordable access to health care services;
  • Local living conditions/environmental issues;
  • Socioeconomic and cultural issues impacting health delivery around affordability of care, health literacy, and cultural context of recommended care alternatives (for example: hospice care)

In my last article, I addressed the SDHs related to health care access, health literacy and patient engagement. This post will focus on the challenging topic of one’s living situation—specifically, access to health-related resources beyond healthcare, such as:

  • Safe neighborhoods;
  • Access to healthy food choices;
  • Access to transportation;
  • Access to green spaces and active lifestyle choices;
  • Physically accessible housing and in-home resources for bathing and toileting

At first blush, these access issues related to one’s living situation seem to fall outside of the responsibility of care teams managing populations at risk of hospital admission or readmission. But in value-based care delivery, it is critically important to broaden your view of these needs and your responsibility to help address them.

Here are just a few examples of well-established, research supported connections between an individual’s living situation and health.

  • Individuals living in violent neighborhoods leads to higher rates of depression, PTSD, anxiety and chronic disease.
  • Individuals living in a neighborhood with easy access to supermarkets have lower rates of obesity and chronic disease while the opposite is true of individuals living in neighborhoods with high numbers of fast food restaurants.

If you’re not convinced, take a ride with any home health nurse for a day and see what goes on in the home setting, often well beyond the visibility of traditional care providers. You will find that your care plan for a patient is first filtered through the lens of their living environment and living situation. For example, we often tell patients to “be more active”. Well, that is hard to do when your neighborhood is not safe, or you don’t have access to walking paths, or you can’t get outside easily because you live in a four-story walk up and have COPD. We often tell patients to “make healthy food choices”, but forget that they may live in a food desert. Or we question why they have recurring urinary infections but we are not aware of their inability to bathe due to physical limitations.

Beginning to account for the challenges of living situations

Many of our best and brightest healthcare leaders are learning about ways to address the challenges of living situation as a high impact opportunity within population health. For example, a recent Aspen Institute Summit called Spotlight Health featured a panel discussion on the role of community health workers in reaching the needs of hard-to-serve individuals and communities, decreasing death rates, and improving health, called “The Last Mile in Community Health”.  (You can watch the discussion here.)

While the living situations of our patients might seem to be one of the toughest social determinants of health for providers to impact, we know that even the most challenging living situation can be addressed when we know it exists.

So where should healthcare leaders start when trying to determine how living situations are impacting their at-risk populations?

Solution #1: Start with knowing the ZIP code of each of your patients.

It turns out that ZIP code matters, not just in terms of socio-economic information, but also in terms of levels of violence, access to healthy food choices, types of housing, and access to green spaces. One great resource is websites like Neighborhood Scout.  Another is ESRI, a geomapping website that will show demographic, economic and profiling information. Or check out this custom application of geomapping technology from California that shows quality performance by ZIP code for different payer segments and for different HEDIS measures.

Solution #2: Talk to your community health providers.

You’d be astounded at what you learn by being in the homes, apartment complexes, and neighborhoods of patients. And what you might not be able to learn from ZIP code data, you’ll be able to learn from talking to community health providers. The best resources are home health agencies, ambulance and EMT services, and community health workers. It takes a bit of work, but if you come with a set of specific questions, you’ll almost always find a receptive and informative audience who loves knowing that you are interested in their work and their knowledge.

Solution #3: Query and assess individual living circumstances across your patient population.

Most healthcare executives who are accountable for the utilization and quality of care across populations have come to the conclusion that they need to regularly assess health risks. Often, a health risk appraisal is a formal part of a matured population health care model. At Pharos, we suggest taking this important tool to the next level in two important ways:

  • Begin assessing living circumstances (and other SDHs) as part of your annual health risk appraisal programs;
  • Use a patient engagement technology platform to query “at-risk” patients regularly about where they need your help to address living situation challenges like safely performing activities of daily living (such as bathing or toileting), transportation needs, diet choices and food resources, etc.

A patient’s living situation is a major driver of his or her health status. Those organizations that understand and do their part in addressing social determinants of health can make a meaningful difference in reducing avoidable admissions and readmissions for their at-risk populations. I’d love to hear your thoughts on this topic–are you looking at the social determinants of health for your patients? If not, why not? If so, how are you incorporating it into your plans? Please feel free to drop a comment in the box below.

Additional Resources

Defeating the Zip Code Health Paradigm: Data, Technology and Collaboration are Key

Violence and Health: What’s the Connection?

Curtailing Food Insecurity with Clinical Community Collaboration

Geomapping Health-related Data

Header image credit: Little Neighborhood by Rachel Elaine on Flickr.


Dr. Randall Williams, MDSocial Determinants of Health, Part 3: Where Patients Live

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