Panelists Outline How to Address Patients’ Social Determinants of Health, Why It’s Important

Taking the first steps to address patients’ social determinants of health (SDOH) can be as simple as asking them about the challenges they are facing in their lives and what’s going on in their communities, said one panelist at a session yesterday.

“Clinicians have a front-row seat for viewing the impact of health inequities and our country’s failure to address issues around the social determinants of health,” said Patrice A. Harris, M.D., M.A., a psychiatrist in private practice in Georgia who has served as a public health administrator, patient advocate, and medical society lobbyist. She believes that clinicians are obligated to share patients’ difficult stories with elected officials and the media, added Harris, who was also the first Black woman to be elected president of the AMA and is a former member of APA’s Board of Trustees.

After deciding which SDOHs to prioritize in patients’ care, Harris said that clinicians should gather a team and develop partnerships with colleagues to help them address these issues. “No one should feel like they have to have all the answers.”

Although there are nearly a dozen social factors that have been clearly identified as important to health, consensus has not been reached on which of these determinants can and should be captured in electronic health records (EHRs), pointed out Regina James, M.D., who posed questions of panelists during the discussion. James is a deputy medical director at APA and the director of APA’s Division of Diversity and Health Equity.

Rather than endless discussion of which social determinants to use, Harris said clinicians should focus on understanding what’s going on in one’s own community and then work on getting the three most pressing social factors added to the EHR. Another barrier to greater attention to social factors is that EHR software vendors sometimes charge extra for modules that allow clinicians to capture and record this type of information. She said clinicians should advocate for lawmakers to hold EHR vendors accountable for creating features that allow clinicians to capture social factors data in a meaningful way from patients.

The Centers for Medicare and Medicaid Services has outlined how to use SDOH-related ICD-10 Z codes (which range from Z-55 to Z-65) to document, for example, that a patient is experiencing problems related to employment, housing, or obtaining food. Analysis of the data can help improve quality, care coordination, and experience of care with the goal of improving patient outcomes. However, James pointed out these are not widely used.

“All of us want data that can help us help our patients,” Harris replied. But greater adoption of these codes may be an uphill battle, she said, in part because payors are not incentivizing the use of the codes and because of lack of consistency capturing and charting this type of data.

Harris said there is increasing pressure on clinicians to do more to measure patient outcomes. “We do have a moment now where there is increasing focus on mental health, but the criticism (from payors and employers) has been ‘I don’t know if I’m seeing a return on my investment or if I’m seeing more bottom-line employee productivity,’” she said. She said psychiatry needs better tools to measure patient outcomes and whether what psychiatrists are doing is improving the health of patients.

It has been well established that having good social connections is a critical SDOH; it can have a greater impact on longevity than even an individual’s smoking, drinking, or exercise status, according to Dilip V. Jeste, M.D. He is the senior associate dean for healthy aging and senior care and the Estelle and Edgar Levi Memorial Chair in Aging and Distinguished Professor of Psychiatry and Neurosciences at the University of California San Diego. “We are a social species by nature.”

In fact, research has shown that good social connections help individuals build lasting resilience against distress. For example, after the Hurricane Katrina disaster in New Orleans in 2005, research found that individuals came together to help each other and that these strong social supports helped shield many people from developing expected posttraumatic stress disorder, despite their experiences, he said.

“There is something wrong with our social and legal systems that our patients are dying 15 to 20 years earlier than the general population, and those gaps in mortality have only increased in the last few decades,” Jeste said. “More of our patients are in jails and prisons rather than in hospitals, and that is not true of the patients of any other medical specialty.”

While better medical care and nutrition and cleaner water supplies have boosted human longevity in recent decades, Jeste said people with mental illness have not benefited from these advances. That’s because individuals with mental illness are less likely to get physicals or preventive screenings. “They go for years with undiagnosed hypertension, which leads to stroke,” he said.

When it comes to treating older patients, Jeste said clinicians often forget to ask them about their alcohol or substance use or fail to pick up on their depression because it is subsyndromal. “Yet this age group has one of the highest rates of suicide.”

For older patients, ageism, loneliness, and social isolation are critical concerns, Jeste said. “Where I come from in India, there is the belief that older people are wiser and have much to contribute. Here the aging of the global population is seen as a ‘Silver Tsunami,’ as if it’s a natural disaster happening to the world.” He prefers to view it as “a Golden Wave,” he said, to help older individuals learn to view their age as a positive. Older adults “can share their wisdom with younger people and provide leadership.” ■