There has not yet been established a consensus on the set of factors to use for assessing social determinants of health in practice.
There's really no single consensus on the set of factors that define social determinants of health (SDOH), explained Megan Coleman, PharmD, BCPS, CPP, during her presentation at the APhA 2023 Annual Meeting & Exposition. There are various factors and nomenclature that are incorporated into each framework for assessing SDOH, and they very commonly incorporate economic and socio-economic factors as focal points of assessment.
“Another thing that's important for us to recognize and understand as pharmacists is that we have a lot of overlay and a lot of complex interactions here among our [SDOH]. A lot of them kind of intertwine,” Coleman said. “I think it's also important for us to pause, recognize, understand, and advocate for the structural and legal influences that are very heavily involved with [SDOH].”
Clinical context alone, however, is too narrow when addressing systemic SDOH influences, Coleman explained. Instead, structural and legal interventions are needed to address the root causes driving SDOH.
“So again, I think this highlights a need for the advocacy and change from some of the structural and legal influences,” Coleman said.
Healthy People 2030 defines SDOH as conditions in the environments in which people are born, live, work, play, worship, and age, Coleman explained. These are often thought of as non-medical factors that influence health outcomes.
“There are a lot of different numbers that you'll see in the literature, but it's traditionally thought that about 60% to 70% of health outcomes are going to be heavily related to behaviors that are influenced by the environment,” Coleman said. “We contrast that with only 10% to 20% of health outcomes being related to direct medical care—that's a pretty significant gap there in the shift in how we see health.”
Healthy People 2030 identified SDOH as one of their main focus areas for the next 10 years, with 5 core domain areas. These domains include education access and quality, health care access and quality, economic stability, social and community context, and neighborhood and built environment.
“When we look at [SDOH] and influence in diabetes and diabetes outcomes, we see some really staggering statistics,” Coleman said. “Across the board, we see a very high rate of adults in our country that have limited or low health literacy. When we look specifically at diabetes, we see a high percentage of individuals reporting financial stress, costs related to underuse of insulin, food insecurity, and housing instability.”
The American College of Physicians and American Diabetes Association, which provide the 2 sets of clinical practice guidelines for diabetes care, are now recognizing and recommending screening and addressing SDOH when caring for individuals living with diabetes. There's also more recently been a call for interventional trials that address these areas, not only in diabetes, but also other chronic disease states as well, according to Coleman.
When screening for SDOH, there's really no preferred single screening tool that providers should be using. Instead, the SDOH screening tool selection will depend on the provider’s needs and the needs of their patient population.
“The other thing here is that these [screening tools] can be administered by a clinical or non-clinical staff member, but patients can also self-administer these tools,” Coleman said. “One thing that we may see in our practice is if patients are self-administering these tools, they may be more likely to disclose sensitive information, versus having it administered by you or another clinical or non-clinical staff.”
There are 3 SDOH screening tools in particular that Coleman recommended for patients with diabetes. The first is the EveryONE project from the American Academy of Family Physicians, the second is the Protocol for Responding to & Assessing Patients' Assets, Risks, and Experiences (PRAPARE), and third is the Accountable Health Communities Health-Related Social Needs (AHC-HRSN) screening tool, which was developed by the Centers for Medicare & Medicaid Services.
“This one is very commonly used in the Medicare and Medicaid patient populations,” Coleman said. “Sometimes within health systems, we may see these embedded within the electronic medical record, and sometimes certain state departments of Health and Human Services may offer additional screenings as well—I know that's the case for me in North Carolina, where I live.”
Coleman M, Pauling EE. Crossroads in Diabetes Care: Social Determinants of Health. Presented at: APhA 2023 Annual Meeting & Exposition in Phoenix, AZ; March 27, 2023.