Health Disparities and the Social Determinants of Health as Pharmacists

BY SARAH A. ALSOMAIRY, Pharm.D., M.S., PGY-1 resident; LAMA HSAIKY, Pharm.D., BCPS, clinical pharmacy manager; and NEHA DESAI, Pharm.D., pharmacy director, Corewell Health Dearborn Hospital

In the United States, health inequity and health disparities have been ongoing issues – despite efforts made to improve access to health care.(1) Race, ethnicity, poverty and community may all be contributing factors and determinants to health inequities, as well as negative health outcomes.(1)

The World Health Organization (WHO) defines social determinants of health (SDoH) as the "conditions in which people are born, grow, live, work and age; and are shaped by the distribution of money, power and resources on both a global and local level." This encompasses five branches: education access and quality; health care and quality; neighborhood and built environment; social and community context; and economic stability.(1) For example, individuals from lower socioeconomic backgrounds have worsening health outcomes and higher exposure to chronic disease states when compared to individuals from higher socioeconomic status.(1) The prevalence of specific diseases in patients from this background may be due to numerous factors, including limited access to healthcare, medications, poor nutrition and discrimination.

The American Pharmacists Association (APhA) and other health organizations recently released a public statement encouraging racial diversity, equity and inclusion (DEI) in all areas of health care, including patient care.(2) This includes incorporating DEI concepts addressing SDoH disparities and cultural competence into the health care educational curriculum.(2) In addition, starting in 2024, the Centers for Medicare and Medicaid Services (CMS) will mandate health systems to report to the Inpatient Quality Reporting Program two new measures; SDoH-1 (Screening for Social Drivers of Health) and SDoH-2 (Screen Positive Rate for Social Drivers of Health). These two measures will screen all admitted patients for SDoH factors; of those screened, it will account for how many have one or more social risk factors.(3)

Pharmacists can play an essential role in identifying social needs and positively impacting health outcomes. In 2018, the American Society of Health-Systems Pharmacists (ASHP) released a statement identifying pharmacists' important role in SDoH. ASHP stated pharmacists are equipped for promoting and maintaining public health by contributing to team-based monitoring, educating patients and screening for social determinants of health.(5) Numerous studies assess pharmacists’ influence in various settings and diverse patient populations. These studies demonstrate that pharmacist involvement, including discharge counseling, medication reconciliation upon discharge and longterm follow-up, reduced hospitalizations and readmission rates, and increased financial benefits to institutions.(6-8)

When examining SDoH, it is important to analyze the branches as a whole, as one branch may affect another, leading to a domino effect. This is where a group of pharmacists at Corewell Health Dearborn Hospital (formerly Beaumont Dearborn) has taken the initiative. The patient population at our institution is unique regarding cultural and financial perspectives. Approximately 73% of the patient population has publicly-funded insurance. In 2021, of the 19,384 patients, 2,513 were identified as non-English speaking. Another 27 percent were African American, 6.7% were Hispanic/Latino and 15.3% were of Arab descent. In 2022, we received a grant to implement a pharmacist care bundled intervention program. This program aims to improve health outcomes and reduce healthcare costs for underserved patients. The pharmacists clinically assessed the patients, as well as conducted social assessments to identify social barriers that may impact medication management and readmission. Our preliminary data demonstrated that in 298 patients– 195 in a control group and 103 in a bundledcare group – the bundled care-group had a significantly lower 30-day readmission rate than the control group (43% vs. 57%; relative risk

0.73; 95% confidence interval, 0.57-0.95, p=0.015). Overall, pharmacists contributed 593.5 hours over five months, making 269 interventions in 103 patients. The top four pharmacist interventions in the care bundle group were medication reconciliation, therapeutic modifications, assisting with social issues, as well as patient counseling. While the role of pharmacists in addressing SDoH and health inequities is not clearly defined, there are many ways a pharmacist can be integrated to combat health disparities.9 This includes integrating oneself on a patient and community level. Pharmacists can utilize the pharmacist's patient care process (PPCP) during their clinical workup to address SDoH. This includes collecting information regarding the patient's social issue and assessing whether this is a barrier concerning medication access and adherence. They can plan to address these social issues, including referring to social work, case management, or local support services.

In addition, the PPCP lays out all of the critical steps of patient care and facilitates the standard process for pharmacists to provide patient-centered and evidence-based care. Utilizing the PPCP will allow pharmacists to combine the clinical and social aspects of the patient to develop individualized care plans. Other ways pharmacists can address health inequities include culturally sensitive patient education; offering medication cost-saving interventions; contributing to primary care services, such as immunizations and educational courses; and, most importantly, continuing to advocate to expand pharmacy practices.9 In combatting health disparities, it will take all health care team members to become aware of their critical role. As pharmacists and health care providers, we have the privilege to impact health outcomes for underserved patients significantly. Incorporating social aspects into our clinical workup will help shift the narrative from patient issues to societal and close the health disparities gap.

References

1. Whitman, Amelia. "Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts." ASPE, 1 Apr. 2022, https:// aspe.hhs.gov/reports/sdoh-evidence-review

2. Keagy, James. "APhA Press Releases." American Pharmacists Association, American Pharmacists Association, 3 Feb. 2023, https://www.pharmacist.com/APhA-PressReleases/apha-national-organizations-release-statement-on-ensuring-diversityequity-and-inclusion-in-health-care

3. GovInfo | U.S. Government Publishing Office. Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS). . (2022, August). Retrieved March 2, 2023, from https://www.govinfo.gov/content/pkg/FR-2022-08-10/ pdf/2022-16472.pdf

4. World Health Organization. Taking action on the Social Determinants of Health. World Health Organization. Retrieved March 2, 2023, from https://www.who.int/ westernpacific/activities/taking-action-on-the-social-determinants-of-health

5. Cameron, G. (2022, March 1). ASHP statement on the pharmacist's role in Public Health ASHP Statement on the Pharmacist's Role in Public Heal. Retrieved March 2, 2023, from https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/role-ofhealth-system-pharmacists-in-public-health.ashx

6. Sebaaly J, Parsons LB, Pilch NA, Bullington W, Hayes GL, Easterling H. Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study. Hosp Pharm. 2015;50(6):505513. doi:10.1310/hpj5006-505

7. Lisenby KM, Carroll DN, Pinner NA. Evaluation of a Pharmacist-Specific Intervention on 30-Day Readmission Rates for High-Risk Patients with Pneumonia. Hosp Pharm. 2015;50(8):700-709. doi:10.1310/hpj5008-700

8. Kim J, Lin A, Absher R, Makhlouf T, Wells C. Comprehensive and Collaborative Pharmacist Transitions of Care Service for Underserved Patients with Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis. 2021;8(1):152-161. doi:10.15326/jcopdf.2019.0175

9. Kiles TM, Peroulas D, Borja-Hart N. Defining the role of pharmacists in addressing the social determinants of health. Res Social Adm Pharm. 2022;18(9):36993703. doi:10.1016/j.sapharm.2022.01.005