Attending to the social determinants of health is especially important for children, since children’s experiences – of poverty, poor nutrition, trauma, abuse, neglect, the prenatal environment – can affect physical and mental health for an entire lifetime. As the authors of a recent commentary in JAMA write: “Pediatrics … continues to evolve clinical practice aimed at addressing social determinants because of children’s exquisite vulnerability to the deleterious effects of the social and physical environment, especially the aggregation of social factors associated with poverty.”
The occasion for the commentary – titled Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons From Pediatrics — is the imminent implementation of the Affordable Care Act. The medical home (also known as the patient-centered medical home) is a concept that originated in pediatrics. The basic idea is that when a team of providers — physicians, nurses, nutritionists, pharmacists, social workers – work together, they can best meet the needs of patients. The Affordable Care Act has several provisions designed to establish and promote medical homes, and the authors of this commentary (two pediatricians and a family medicine practitioner) ask: What has pediatrics learned about addressing social determinants that can be translated to medical homes for adults.
Guidelines, unmet needs, colocation, home visits, thinking outside the box
The JAMA commentary is behind a paywall, so here’s a brief summary of the main points:
~ Pediatric guidelines stress the importance of understanding the child in the context of family and community. They also stress the influence of social risk factors on children’s health. Adult guidelines for medical homes should likewise recognize the importance of addressing social determinants.
~ Primary care physicians have been educated to pick up on psychosocial issues such as depression, substance abuse, and intimate partner violence. Medical screening of adults could be expanded to include unmet needs (food, employment), followed by referrals to community resources.
~ Urban pediatric clinics often share a location with community services such as WIC nutrition programs. Adult medical homes should consider sharing a location with services for housing, jobs, and food programs.
~ Pediatricians have learned to use “outside the box” interventions to help patients and their families: the Reach Out and Read program, legal services, the Health Leads program that uses college volunteers to assist patients with “prescriptions” for food and housing. Adult medical homes should take advantage of the Affordable Care Act’s financial incentives and use “outside the box” interventions to address social determinants.
~ Pediatric practices have used home visiting programs to assist parents with specific needs. Nurses are able to help families with school enrollment, employment, and social safety net programs. There are home visiting programs for the elderly and chronically ill, but currently they focus on improving mobility and functionality, not social determinants that may affect health.
It’s cheaper to let the sick die
I was encouraged to see the social determinants of health addressed in the Journal of the American Medical Association. The sooner we incorporate this perspective into routine medical care, the sooner everyone will have an equal opportunity to live healthy and satisfying lives.
I was also pleased to see the authors use the argument that addressing the social determinants of health can reduce costs: “If these programs could be shown to improve population health and help to control costs in ways such as reducing hospital admission and readmission, among other important outcome measures, then broad dissemination can occur.”
In the second half of the twentieth century, health care became big business. When the financial interests of stake holders are threatened, change happens slowly, if it happens at all. Stake holders – insurance companies, employers, legislators, hospital administrators, physicians, pharmaceutical companies, the public — will not advocate for policies that acknowledge social determinants simply out of the goodness of their hearts. Presumably they can be motivated by the opportunity to reduce costs and improve profits. But not always.
The argument that addressing social determinants will reduce costs has its detractors, unfortunately. A few years ago Atul Gawande wrote a New Yorker article on how providing better health care and relevant social services to the medically neediest patients could generate considerable financial savings. One published response to this proposal went as follows: If we address the health care issues of the neediest patients, we may save money on their care in the short run. But in doing so, we allow them to live longer. If they live longer, it will cost the health care system more money than was saved. (I wrote a post on this called It’s cheaper to let the sick die. See Can better care for the neediest patients lower costs? for a summary of the Gawande article.)
We may be able to convince many in the medical profession, a few in public policy positions, and even some of the public that addressing social determinants makes good economic sense. But without a cultural and political shift in attitudes towards social and economic inequality, even appeals to the profit motive may be ignored.
Related links:
A culture of health needs a market for health
Why is it so hard to reduce US health care costs?
Can better care for the neediest patients lower costs?
It’s cheaper to let the sick die
Image source: Pointe Pediatric Associates
References:
Arvin Garg, MD, MPH; Brian Jack, MD; Barry Zuckerman, MD, Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons From Pediatrics, JAMA, May 15, 2013, Vol 309, No 19, pp 2001-22001
Atul Gawande, The Hot Spotters – Can we lower medical costs by giving the neediest patients better care?, New Yorker, January 24, 2011
Re: The Hot Spotters: A letter in response to Atul Gawande’s article (January 24, 2011), The New Yorker, February 28, 2011
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