Too often, what is really driving your patient’s health outcomes cannot be discovered in an imaging study, laboratory test, physician exam or office visit.
Laura J. Zimmerman, MD, detailed how primary care physician private practices can address social determinants of health during an AMA Private Practice Simple Solutions session, which is part of a series of free, open-access rapid-learning cycles designed to provide opportunities to implement actionable changes that can immediately increase efficiency in private practices.
“Addressing social determinants of health is critical to the health of patients, communities and the viability of our health systems,” she said, and physicians need a strategy to address the health care issues they raise.
Social determinants, or social drivers, of health are “conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcome and risks,” Dr. Zimmerman noted.
They include the economic stability of the community, education access and quality, health care access and quality, neighborhood and build environment and the social and community context of the care needed, she said.
“We know that the health care we provide is just a fraction of the factors that influence health and well-being, mortality and morbidity,” said Dr. Zimmerman, division chief of general internal medicine at Rush University Medical Center.
There are also growing financial incentives from payers for addressing these factors. “This further motivates health systems to go beyond the exam room … to address unmet social needs,” she said.
8 steps to address social drivers
Dr. Zimmerman outlined the eight-step process below to guide physician private practices to better include social determinants of health in their planning and programs.
- Understand and engage your community.
- Engage key leadership.
- Assess your readiness.
- Select and define your plan.
- Assess social determinants of health at the patient level.
- Link patients to resources that address social determinants of health.
- Evaluate and refine.
- Celebrate your success.
Learn more with the AMA STEPS Forward® toolkit on social determinants of health.
Dr. Zimmerman suggested that physician private practices take advantage of resources such as the Community Health Needs Assessment required by federal regulators every three years or the Community Health Improvement Program that can accompany the assessment.
These reports can be the first step in identifying mutual priorities for your physician private practice in collaboration with local leaders, she said. The discussion can help your practice and its practice-management leaders communicate how you can help local leadership meet their goals as well as yours.
They can also help you assess your readiness to take on select social determinant targets and refine a plan that addresses one or more social determinants, such as food insecurity in a specific community.
Dr. Zimmerman advised that new practices engaging in this process start with a single social determinant, and a single patient subgroup that is easy to identify.
It takes astute clinical judgment as well as a commitment to collaboration and solving challenging problems to succeed in independent settings that are often fluid, and the AMA offers the resources and support physicians need to both start and sustain success in private practice.
Collaboration is key
The collaboration with local leadership and community organizations can also help suggest how your patients can access the additional resources they can provide to support your plan and your patient needs, she explained. It is important to link patients with resources that can actually help you change the outcomes, she said.
Dr. Zimmerman also recommended that private practice leaders develop metrics, workflow, and data collection to track the success of the project and choose among the many industry-evaluation designs available to measure the project success with the data.
The results can then be used to evaluate and refine the project by incorporating feedback from local partners, payers and other related organizations, she said. It is also important to celebrate success by sharing patient stories, recognizing supporters and sharing abstracts at medical conferences to provide insights to colleagues.
Find out more about the AMA Private Practice Physicians Section, which seeks to preserve the freedom, independence and integrity of private practice.
