Improving Quality by Understanding Social Determinants of Health

The healthcare community needs to understand and address the personal and social circumstances that contribute to a patient’s health before they can improve the quality of care, according to 2 presentations in the first segment of the National Committee for Quality Assurance Quality Talks conference in Washington, DC.

The speakers who presented the first 2 sessions of the Quality Talks’ opening segment “Disparities and Other Health Drivers” occupy different roles in the healthcare industry, but both agreed that physicians need to understand what’s important to patients and identify social barriers that can impede progress toward better health.

First, Alexandra Drane, founder and chair of The Eliza Corporation, gave a presentation called “What’s Really Killing Us?” about how life challenges can sometimes be just as harmful as medical conditions. She said that healthcare providers often address the health issues and behaviors they think their patients should be concerned about, but patients are more focused on all the day-to-day stressors in their life.

“We need to expand the definition of health to include life, because when life goes wrong, health goes wrong,” said Drane.

She cited the psychological theory of Maslow’s Hierarchy of Needs, pointing out that patients are less likely to get a good night’s sleep, eat a healthy diet, and exercise regularly if they have more immediate struggles, such as work or relationship stress, or even food insecurity and homelessness.

“These life challenges are diseases in their own right, and they deserve a seat at the grown-up table with the other diseases,” she said.

She ended her presentation by recommending that physicians take a number of steps to address these life challenges. They must ask the right questions about what’s going on in the patient’s life, they must acknowledge with empathy how difficult that situation is, and they should connect the patient with those who are struggling with similar issues, according to Drane.

Many of the themes from Drane’s presentation were echoed by the next speaker, Rishi Manchanda, MD, MPH, chief medical officer of The Wonderful Company. He spoke about how looking upstream to the social drivers of health can help achieve the quadruple aim, which consists of outcomes, costs, patient experiences, and provider experiences.

The parable that guides this theory, Manchanda said, is the story of 3 friends who see that some people in a creek are about to go over the edge of a waterfall. One jumps in near the edge and starts pulling people out right before they fall over, the second walks a little farther up from the edge and builds a raft for the people in less immediate danger, and the third walks much farther upstream to find out “who or what is throwing these people in the water.”

His team uses that concept to help the patients it sees, not just by treating their medical conditions, but by first connecting them with the other resources, like legal counsel or food banks, in order to address their individual situation. This strategy, he said, also alleviates some of the burnout commonly experienced by physicians when they feel helpless to impact more “upstream” drivers of health.

Manchanda concluded his session with some action steps for providers: get ready by assessing their system’s ability to improve social factors; get set by identifying healthcare-based upstream specialists, as well as community partners like food banks; and go upstream by applying basic quality improvement initiatives.

He explained that “upstream medicine” is a theory that lies at the intersection of health systems improvement, social determinants of health, and population health, and he called it “a concept that is pretty common sense."