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Social Determinants of Health

Swimming Upstream: Meeting the Challenges of Social Determinants of Health

It’s been said that patients’ ZIP codes matter more than their genetic codes when it comes to health status. That’s because certain conditions in the places where people live, work, learn and play can pose greater health risks and poorer outcomes. In public health terms, these conditions are called social determinants of health or, sometimes, upstream determinants of health. Basically, the concept is that nonclinical factors influence health outcomes.

Scientific research has proven the concept holds. The Annals of Internal Medicine in 2014 examined rehospitalizations based on patients’ place of residence. Those who lived in the most disadvantaged neighborhoods (defined by a set of measures of socioeconomic deprivation) were at higher risk for rehospitalization. Nearly a third of rural patients lived in such locations.

Certainly, there are social determinants that are more prevalent and problematic in rural communities, including substandard housing; lack of public transportation and ride sharing options; food insecurity; lower education levels; and substance abuse. In general, rural residents are more likely to experience some of the contributing socioeconomic factors that negatively affect health.

Ignoring social determinants of health—which is to say, ignoring the root causes of illness—perpetuates problems and ends up increasing costs for healthcare providers in the long run. Because of these mounting, traceable expenses, community hospitals are increasingly taking an interest in the social determinants of their patient population. Conducting a community health needs assessment or strategically reviewing the results of the most recent CHNA is a good starting point.

Social Influencers of Health

“Social determinants of health” is a buzz phrase, but some, including Valerie Hayes, CHC Planning Manager, find the term too deterministic.

“I don’t like the term because it sounds permanent, as though there is no opportunity to improve certain social and environmental conditions,” Hayes said. “CHC and the hospitals we work with are focused on improving these factors.”

The phrase “social influencers of health” has been offered by Dr. Gregory Simon of Kaiser Permanente Washington Health Research Institute as a more positive alternative.

Community hospitals are looking upstream to try to help meet the fundamental, nonclinical needs of patients; only then can those patients prioritize healthcare. Small hospitals themselves typically lack sufficient resources to go beyond their own walls, let alone upstream, so partnering with local organizations and agencies is the key to success. Many small hospitals already participate in community coalitions with social service agencies, as well as school districts and nonprofits. Some are parlaying those relationships to address social influencers of health.

Upstream Interventions

For example, in McCook, Nebraska, Community Hospital, City of McCook Fire Department and McCook Clinic PC jointly created the Community Paramedicine Program, an initiative designed to reach isolated rural residents who lack access to healthcare. Farther south in Wichita Falls, Texas, United Regional Health Care System teamed up with the Wichita Falls Area Food Bank to support a mobile food pantry service to address hunger and barriers to health access by delivering produce, other healthy foods and screenings. Other hospitals have collaborated on community gardens; accepted nonperishable food items as payment for flu shots which are then donated to local nonprofit organizations; and started offering telemedicine.

Ultimately, unaddressed social influencers worsen financial strain on health providers. For example, hospitals end up absorbing additional costs associated with treating the homeless or those who, on the contrary, are housebound or lack sufficient transportation. What’s more, the portion of hospitalizations that are considered preventable total 64.6 percent in rural areas compared to 50.6 percent in urban areas, according to a 2017 North Carolina Rural Health Research Program study. To provide the best possible care for the patients they serve, it’s clear that community hospitals need to continue looking upstream.

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