11 minute read
What are the Social Deteriminants of Health? Why are they Important?
CARE IN FOCUS -- SOCIAL DETERMINANTS
What Are Social Determinants of Health? Why are they Important?
By Amelia Tilson, NCAFP Summer Intern
As a family physician, you know a person’s health is about more than just their physical body, much more. A person’s health is also impacted by a combination of their mental health, the communities in which they live and work, their relationships and support systems, their early childhoods, and so much more.
This idea of non-medical drivers of health has been labeled Social Determinants of Health (SDOH). These factors play a significant role in health outcomes, as studies have shown that up to 80% of a person's overall health is driven by social and environmental factors. These basic needs (secure housing, stable access to enough healthy food, a job that pays enough, transportation and education, for example) have a tremendous impact on people’s health.
On both national and state levels, non-medical factors that contribute to poorer health are incredibly prevalent. In North Carolina:
• 16% of families with children live in poverty, and it’s even higher among families with at least one child under the age of five (21 percent).
• More than 1.2 million people cannot find affordable housing.
• More than 1.85 million people have low access to a grocery store.
• Almost 44% of women in North Carolina have reported experiencing some kind of violence in their relationships.
• On average, 7% of the state’s population does not have access to a vehicle and reports that it inhibits their ability to access healthcare.
• Nearly one-quarter of children in North Carolina have experienced some kind of adverse childhood event 1 .
These kinds of unmet needs can contribute directly to conditions such as diabetes, asthma, obesity, chronic pain, anxiety, and de-
pression. In order to properly work to better the health of the residents of North Carolina, working to address SDOH must be a part of treatment plans.
Social determinants have a major impact on all health outcomes, but more commonly affect minority communities. Low levels of education, low-income levels, and a poor living environment are all social drivers of poor health. And for hundreds of years, policies and social norms created inequities within society that continue to drive these problems today. Redlining, for example, was a discriminatory policy that denied the opportunity to live in “good” parts of cities based on race or ethnicity. It pushed these groups into less desirable areas, including areas that lacked green space, had limited access to healthy food, or were in close proximity to air pollutants. The National Air Toxics Assessment of
Cancer Risk shows that the most toxic air is mainly in areas with a high percentage of black populations and communities of color2. These non-medical drivers leave these communities vulnerable to conditions such as heart and lung conditions, and further exacerbate health inequities in our nation.
Addressing social determinants of health on a wider scale requires your work as family physicians. There is now a growing knowledge and consensus that in order to address and achieve the well-being of a population all of the factors of health have to play a role, including the non-medical ones. AAFP released an article in which they explained that a substantial proportion of health care to America’s underserved populations is provided by family physicians and that family physicians are the first line o f care for many families and young children. Your role as the first line of care means that there is an
opportunity to integrate the social determinants of health and their impacts into screenings, diagnoses, and treatments.
What barriers are your patients facing that are preventing them from accessing their basic needs? What services are they lacking in their communities? Implementing these kinds of questions surrounding SDOH can aid in catching early signs of conditions such as diabetes and asthma, as well as being able to more holistically understand a patient and their needs. So, in order to properly be able to treat families and children, social determinants must be a part of the diagnostic conversation.
Approaches in North Carolina
There are multiple systems being set up in our state to address this idea of whole person health and incorporate social determinants and non-medical factors into care. NCCARE 360 and the Healthy Opportunity Pilots are two systems in our state that have been developed to assist in aiding patients and providing them with access to the non-medical services they need to achieve healthy living. These programs are setting up systems that allow people to access resources to meet their basic needs and are making healthcare more holistic. Learn more about these two landmark programs in the additional articles that follow.
References
1. All stats from: North Carolina Department of Health and Human Services. “Using Standardized Social Determinants of Health Screening Questions to Identify and Assist Patients with Unmet Health-related Resource Needs in North Carolina” April 5, 2018.
2. One reason why coronavirus hits Black people the hardest. (May 22, 2020) . Vox News. from https://www.youtube.com/ watch?v=XAFD-0aMkwE
By Amelia Tilson, NCAFP Summer Intern
The North Carolina Department of Health and Human Services (NC DHHS) is embracing the idea of whole person health, and the idea of buying health, not healthcare. One key part of their work is the Healthy Opportunities Pilots. The Healthy Opportunities Pilots are the nation’s first comprehensive program to test and evaluate the impact of providing and paying for (with Medicaid dollars) select evidence-based, non-medical interventions related to housing, food, transportation, and interpersonal safety and toxic stress of high-needs Medicaid enrollees.
These pilot programs are part of the flexibility that NC DHHS received through the 1115 Medicaid Demonstration Waiver. The 1115 Waiver is an agreement between North Carolina's Medicaid program and the federal Center for Medicare and Medicaid Services (CMS), that allowed North Carolina to transition the Medicaid program from fee-for-service to managed care. As a part of that waiver, CMS authorized North Carolina to spend up to $650 million dollars of Medicaid funds to develop the Healthy Opportunities Pilots. The largest portion of the authorized spending will pay for a set of evidenced-based, non-medical services that are not typically covered by Medicaid.
Traditionally, Medicaid only covers medical care: doctor’s visits, prescription drugs, in-patient and outpa-
Healthy Opportunities Network Leads and Regions
Awarded Healthy Opportunities Network Leads
Access East, Inc.
Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northhampton, Pitt.
Community Care of the Lower Cape Fear
Bladen, Brunswick, Columbus, New Hanover, Onslow, Pender.
Impact Health
Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey.
tient care, etc. While these are important to a person’s health, about 80% of a person’s health is driven by non-medical factors, such as housing and food access. Through the pilots, North Carolina has the opportunity to provide services to assist with non-medical drivers of health. The Pilots focus on four specific domains: housing, food, transportation, and interpersonal safety/toxic stress. NC DHHS created a fee schedule that defines and priced a set of 29 non-medical services that are being tested through the Pilot Program.
Currently, the Pilot Program is authorized to operate in three rural regions of the state for people enrolled in Medicaid Managed Care: two regions in the eastern part of the state and one in the western part of the state. These are shown in the map above.
The Access East pilot serves these counties: Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, and Pitt.
The Community Care of the Lower Cape Fear pilot serves these counties: Bladen, Brunswick, Columbus, New Hanover, Onslow, and Pender.
And lastly, the Impact Health pilot serves these counties: Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, and Yancey.
Individuals enrolled in Medicaid Managed Care must meet both a physical or behavioral health criteria and have at least one social risk factor to qualify to receive pilot services.
A second goal of the Pilot Program is to further develop the infrastructure throughout North
continued on BACK COVER
What is NCCARE 360 and How Can It Benefit Your Practice
By Amelia Tilson, NCAFP Summer Intern
NCCARE 360 is another product of the North Carolina Department of Health’s aim to buy health, not healthcare. NCCARE 360 is a relatively new statewide system that aims to better connect health and human services providers by electronically linking patient needs with resources to accommodate their needs and create a feedback loop to ensure quality care is being provided. NCCARE 360 has two main components: a statewide resource directory and a software technology platform.
The resource directory contains a multitude of resources that your patients may need access to, but have a hard time finding, such as housing, food, clothing, transportation, and more. This resource directory is available in all 100 counties and includes over 13,000 service listings in over 26,000 service locations. The resource directory also contains a call center with trained navigators who can help clients find what they need to, as well as online chat capabilities to ensure that the website is as easy to use as possible.
Unite Us created the software technology platform that onboarded the resources from the directory, as well as additional resources such as health care and social services providers. Prior to NCCARE 360, health care and social services in North Carolina were siloed from healthcare. There was no infrastructure connecting these two systems, which led to many patients falling between the cracks. This platform works to streamline referrals for patient needs, and essentially creates a “no-wrong-door” approach making the resource list one that can be more
easily implemented into North Carolinian’s lives, rather than just a list of intangible resources. Additionally, this platform will create a closed loop referral system which will ensure that there is follow-through from the resources in the database. Just like you connect patients with cardiologists and orthopedists, you can connect patients with resources that can work to address the non-medical drivers of health. Within this closed loop referral system, physicians or your team can safely and securely send and receive electronic referrals and track patient outcomes and information. For example, you as family physicians can identify a problem such as Billy with diabetes having trouble getting his condition under control. You find out that Billy is having trouble controlling his diabetes because he has limited access to healthy foods. So, you use the resource directory to connect Billy with his local food pantry, and they set up a box of healthy foods for Billy to pick up a few times a week. But, Billy lacks access to transportation to get to and from the food pantry to collect his basket of healthy food. This technology platform can help connect patients with transportation, making sure that patients not only have access to resources such as healthy foods, but they also have the means to get there to access them. The food pantry confirms when Billy picks up his box to you as his doctor, and you can ensure Billy is taking the
proper steps to control his diabetes, hence creating this closed loop referral system. The resource directory and online technology platform are incredibly transformative for healthcare around the state, but are not useful if all members of a team are not trained to use it. To support all communities in 100 using this tool to its fullest extent and see its full outcomes, NCCARE 360 has
NC COUNTIES a community engagement team powered by Unite Us who work with community-based organizations, 2,500+ health systems, government agencies, and health ORGANIZATIONS care and social services providers to get them onboarded onto these online platforms. They can help 42,000+ onboard your practice directly.
USERS It has been proven that 80% of a person’s health is shaped by non-medical drivers of health. As North Carolina shifts into value-based payments for healthcare, it is now even more important to ensure patients are having the best outcomes. Within the closed loop referral system, there is an opportunity for members of your team to make sure that all the necessary connections are being made for your patients. As family physicians, utilizing NCCARE360 can help you achieve the best possible outcome for patients, which rewards both you and them, creating a win-win for both parties.
Amelia Tilson is a rising junior at the University of Richmond majoring in Leadership Studies and minoring in Health Studies, on track to graduate in May of 2024. She is a Raleigh native and graduated from Enloe High School in June 2020. During her senior year of high school, she began realizing her interest in public health and public policy. As a result, during her first two years of college, she took classes that provided her a better understanding of what those worlds mean. She is very interested in the social justice aspect of healthcare, and after college anticipates entering the public health policy field.
