Just in case physicians, other health professionals or the public don’t fully appreciate the importance of patients’ social determinants of health, Alma Ratcliffe, MD, makes it one of the first things she talks about.
What physicians do “only contributes 10% to the health and well-being of the patients they serve, and about 30% is genetics,” said Dr. Ratcliffe, vice president and chief clinical transformation officer at Saint Peter’s Healthcare System in New Brunswick, New Jersey. “In reality, 60% of the health outcomes for that particular patient are directly correlated to the social, environmental and individual behavior of the patient.”
If physicians and health care organizations don’t work to help “address the 60%, we really are not managing the patient to their full health and well-being,” she added.
Saint Peter’s is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Saint Peter’s was on a strategic path to more aggressively address their patients’ social determinants of health (SDOH), but it became “a strategy on steroids,” Dr. Ratcliffe said, after it became clear early in the COVID-19 pandemic that the most critically ill patients could be traced back to certain nine-digit ZIP codes, also known as “ZIP Code +4.”
Using a nationally standardized questionnaire, Saint Peter’s began to screen their mostly Hispanic patient population for social determinants of health and identified transportation and food insecurity as their major concerns. Evidence shows that screening for SDOH can have a positive impact on patients’ health.
“The association of patients’ social needs—such as food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence—with health outcomes and costs is increasingly recognized by the medical community,” says a study published in JAMA Network Open. “And an increasing amount of evidence documents that physician- and hospital-led interventions addressing patients’ social needs can produce improved health outcomes and less costly medical care.”
Food insecurity a top concern
Saint Peter’s started its work on social determinants of health with a pilot program involving 130 patients. The effort has grown considerably, with more than 2,000 patients having been screened since June at the Saint Peter’s Family Health Center.
That’s where Ishani Ved, MHA, director of transformational population health and outcomes at Saint Peter’s, works with two bilingual SDOH coordinators with backgrounds in social work and epidemiology to connect patients with social services they need.
She also works with a transportation coordinator who has just been hired. A recruitment effort is underway to hire a third SDOH coordinator.
To address patients’ concerns about reliable access to healthful meals, the center collaborates with local farmers’ markets and provides vouchers to patients so they can obtain nutritious food.
“We do a quick questionnaire, and we hook them up with resources that they would need based on whatever needs are identified, or if there are potential government subsidies,” she said.
This may include the Supplemental Nutrition Assistance Program and school lunch programs. If they qualify, patients may also be linked to programs for prescription assistance and utility subsidies.
There is a nutritionist on site and patients learn how to identify excess sugar and sodium by reading food labels. The center maintains its own garden from which patients can take home produce. Patients also can learn how to grow their own tomatoes, eggplants, lettuce and other vegetables.
“We teach them that’s it’s not that hard to do and you can actually grow tomatoes in a small pot,” Dr. Ratcliffe said. “We really go to the crux of our patients’ socioeconomic situation so that we can help make a huge difference for them.”
Future plans include a food market using predictive analytics gleaned from screening data and other sources to stratify patients’ risk for illness and hospitalization.
“We used the same tool during the pandemic, and it was really very accurate in predicting which of these patients were going to end up in the hospital,” Dr. Ratcliffe said. “We were quite astonished by that.”
Full spectrum of services provided
The Saint Peter’s Family Health Center offers many of the same services as do federally qualified health centers, such as adult medicine, women’s health, prenatal care, pediatrics, physical therapy and behavioral health counseling.
This includes a “partial hospitalization” program called “For KEEPS” (Kids Embraced and Empowered through Psychological Services) in which children can stay during the day and then are released to their parents.
The program “helps children with behavioral issues—they may be suicidal, acting out in school, or may have interactions with law enforcement—and the schools may not have the services to help them academically as well as socially and psychologically,” Dr. Ratcliffe explained.
“Working with law enforcement and the schools, we provide both academic and psychological services to these children, ages 5 to 17, so that they don't lose that opportunity to enhance their quality of life, address their mental health issues that they're experiencing while providing them with academics,” she added.
Along with academics, children participate in individual and group therapy, get their prescriptions managed and receive lunch.
There is also a child-protection center that provides crisis intervention, child-abuse assessments and referrals to community resources staffed by physicians, nurses, psychologists and clinical social workers trained to recognize and help victims of abuse.
The center averages about 60,000 visits a year, but projections indicate that will grow to 100,000 in the next five to seven years. An expansion that will be completed this year will see the center grow to 76 exam rooms from 49.
“We have really exploded in terms of how many patients we're able to reach,” Ved said.
An AMA STEPS Forward® toolkit defines social determinants of health and their impact on an individual’s well-being, identifies methods to understand a community’s health needs and ways to engage residents in improving the overall health of their community, and explains how physicians can formulate a plan to address SDOH in their practices.
