Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act

Abstract

Understanding the social determinants of health (SDoH), social risk factors, and health-related social needs (HRSN) is critical to creating equitable health and care for all patients and communities. Health care systems need to understand their role in enacting relevant strategies, processes, and policies. One way that health care systems can explore what processes and policies work for their patients and their community is using the Plan-Do-Study-Act (PDSA) model. This discussion paper provides frameworks and approaches to using PDSA cycles to implement SDoH, social risk factors, and HRSN efforts, as a follow-up to the 2017 NAM Perspectives discussion paper Social Determinants of Health 101 for Health Care: Five Plus Five [1].

Association Between Self-reported Health-Related Social Needs and Acute Care Utilization Among Older Adults Enrolled in Medicare Advantage

“…These findings support efforts by CMS, Medicare Advantage plans, and care delivery organizations to achieve population-level screening for HRSNs among all older adults and to underscore the need to address HRSNs in the broader Medicare program, not just among specific groups of high-need patients. 11 , 25 , 26 Notwithstanding the need for broadly focused efforts, the disproportionate burden of HRSNs among specific racial and socioeconomic subgroups of Medicare Advantage beneficiaries necessitates some focused initiatives to improve health equity.…”

Evaluating the complex association between Social Vulnerability Index and trauma mortality

“…When considering policies or programs that may impact the association between SDOHs and poor health outcomes, social health needs are often classified as "upstream" factors (such as income inequality, unequal investments in infrastructure and the built environment, and lack of social cohesion) or "downstream" factors (such as food insecurity, housing instability, lack of transportation). 3,7,37,38 Our findings suggest that the association between SVI and inpatient trauma outcomes is complex, and mitigating disparities in inpatient mortality will likely require investment in upstream policies and programs targeting injury prevention and reducing the severity of injuries sustained. Given the stepwise increase in injury lethality seen across SVI quintiles, interventions upstream from the injury itself may be the key to reducing the disparities in trauma mortality.…”

Social determinants of health screening and intervention: A cystic fibrosis quality improvement process

“…In accordance with screening recommendations to incorporate patient perspective, a final question was added to the screening tool asking respondents if they would like to receive assistance. 12 Respondents who answered “yes” were defined as having requested assistance.…”

“… 11 Social risk factors can be conceptualized as a downstream effect of SDoH. 12 For example, SES is an SDoH that influences the neighborhoods where people can afford to live and therefore their housing conditions. 13 Where people live can also create challenges in accessing food.…”