Supporting individuals to achieve their best health and well-being entails removing barriers and addressing the 2 sides to social determinants of health (SDoH). We can organize these into modifiable and non-modifiable factors.
Modifiable factors include commonly known SDoH aspects like healthcare access, literacy, income, and education.
Non-modifiable factors like age, race, ethnicity, and rural location are not causal factors for disparities, though they're subject to structural inequities that commonly produce adverse health outcomes.
Delineating the differences between modifiable and non-modifiable factors is vital to identify the changes needed at the societal or systemic level. In this article, we'll focus on modifiable factors, providing guidance and examples around tools, strategies, and interventions used to support individuals and their communities in creating positive change toward their definition of health.
SDoH modifiable vs. non-modifiable factors
The distinction between modifiable and non-modifiable factors may be subtle in some instances. Clearly, age and genetics are fixed. Still, an individual's income can be caused by a complex set of modifiable factors, including access to skills training and literacy services in one's community alongside one's personal beliefs and assertiveness to seek free or low-cost options.
Creating change that supports health and health equity for non-modifiable factors requires federal, state, or city policies, healthcare, and non-profit organizational investment and partnerships. It also requires regulations that support and enforce equitable systems and structures.
Four categories of modifiable factors highlight a person's sphere of influence
Modifiable factors span 4 categories, from environmental and socioeconomic to sociocultural and individual. Individuals have the most potential to influence their own thoughts and behavior; however, their power and influence on the broader categories decrease unless they exercise self-advocacy, join with others to push for change, or receive outside support and resources.
Category 1: Individual knowledge, skills, and attitude
Category 2: Sociocultural influences like peers, family, and religion
Category 3: Socioeconomic factors like employment, education, and income
Category 4: Environmental factors like geographical location, access to health services, and technology
How much control does an individual have over their health? With the right support, programs, and encouragement, an individual can determine their own definition of health and what they are willing to do to improve their health and quality of life. In absence of the support, there are also many internal and external constraints and barriers to creating and sustaining positive change. People need mental energy, time, and resources to devote to bringing about long-term, permanent change.
Broader modifiable factors vs. disease-specific modifiable factors for SDoH
Half of all deaths in the US are premature and preventable. And each of the most prevalent causes of preventable death has corresponding modifiable factors influencing health. For example, smoking tops the list of modifiable behaviors that affect cardiac health. According to Johns Hopkins, cigarette smokers are 2 to 4 times more likely to get heart disease than nonsmokers.
Broad modifiable factors not specific to a disease include an individual's lifestyle, behaviors, emotions, and beliefs. What value does a person place on their health? Do they possess the commitment and attitude necessary to sustain healthy behaviors? How can providers best aid their patients?
Supporting positive individual change
To increase the opportunity for effectiveness, interventions must be personalized. Each person's situation, background, and context differs, and solutions need to account for these variances. A health equity or population health professional might encounter many profiles in their work: single mothers, isolated senior adults, young people escaping violence, people experiencing hidden homelessness, non-status refugees, and people living with mental health or substance use disorders, to name a few.
With this in mind, below we outline 7 areas where providers, payers, and community partnerships are improving individual and population health by targeting modifiable determinants of health.
1. SDoH and social risk screenings
The 2023 HEDIS quality measures include a social need screening and intervention measure that examines food, housing, and transportation needs. The inclusion of 2 new items: the percentage of members who were screened and the percentage of members receiving interventions-establishes a greater focus on the most critical step, which is identifying a social need.In an AJMC article from 2020, Dr. Sachin Jain highlighted the need for evidence-based screenings, stating:
“Selectively providing social resources to those most in need requires an accurate and reliable method of identifying these individuals. Although most hospitals screen at least some patients for health-related social needs, this screening is often fragmented and ad hoc."
While there is no standard method for social needs screening and few screening tools are validated, organizations can develop screening tools collaboratively with patients, clinicians, and community partners.
Programs like WellRx in Albuquerque, New Mexico, show that social needs can be uncovered when a screening instrument is used consistently and systematically. Their pilot found that nearly half of patients screened had at least 1 area of social deprivation, and 63% of those had more than 1 need. And, because most of these needs were previously unknown to the clinicians, this study also reflects the lack of transparency into the social needs of patients.
Nemours Children's Health uses a digital SDoH screening tool, making it easier for pediatricians to address the social factors affecting children and their families. Notably, the organization asks specific questions that fit the social services where Nemours has established partnerships.
Hackensack Meridian Health created a network-wide strategy to address the social determinants of health. They use a digital platform integrated with their medical records software, enabling them to screen 5,000 patients daily for non-medical needs and provide more than 1.5 million referrals to community resources since July 2021.
CommWell Health used the CMS grant model to assess unmet social needs, provide navigation help, and create an inventory of community service organizations. As the only rural member of 9 demonstration sites, theirs serves as a best practice model, supporting individuals living with HIV and AIDS.
Younger patients want social determinants of health screenings
SDoH screenings require building rapport and trust between individuals. Many people are hesitant to talk about these issues; however, younger people are open to it. In a survey by the University of Michigan, 81% of people ages 14 to 20 said they want to discuss social determinants of health screenings with their providers in person.
2. Building trust and discovering an individual's “why"
Prioritizing and building patient trust is critical to SDoH screening success and learning the upstream causes or hidden issues that affect a person's health and well-being. One effective way to connect with an individual and discover their beliefs about health and discover how best to support them is to tap into their definition of health and their “why" for becoming healthier.
Dr. Cate Collings, president of the American College of Lifestyle Medicine, says, “Conversations about behavior change became much easier and rewarding after I learned to do less directing and telling and more asking and listening." She shared a story of connecting with a patient where she discovered that taking a trip was something that the patient didn't think was possible but was very important to her. Dr. Collings used that desire to share possible actions the patient could take to improve her health and manage such a trip, which the patient eventually achieved.
3. Behavioral psychology and health coaching
Beyond social need assessments, other ways to discover unmet needs and patient health goals include behavioral psychology and tools like health coaching. Dr. Collings cites “a body of scientific literature" that supports “the psychology and the logistics of behavior change and health coaching." As she says, motivational interviewing and in-person or tele-coaching are foundational methods and “can be more effective than sharing didactic materials to help patients achieve specific outcomes."
Translating the patient's "why" statement into actual behavior change can include identifying the patient's strengths, capacity, confidence, personal network, and readiness to change. The adoption of reimbursable CPT codes will support the integration of health coaching into clinical care.
A study published in the Journal of General Internal Medicine presented the value of telephone health coaching in improving patients' Patient Activation Measure (PAM). Enrollment in the structured, six-month prevention program was higher than in other programs, and the mean PAM score improvement was 2.5 points.
4. Value-based use of SDoH interventions
The PAM score is a helpful indicator that patient behavior change is effective. Research published in the Annals of Family Medicine identified strategies that improved PAM scores through an ACO. According to their research, “Clinicians whose patients had relatively large activation increases reported using 5 key strategies to support patient behavior change."
The 5 strategies cited as most useful by physicians included:
- Emphasizing patient ownership
- Partnering with patients
- Identifying small steps
- Scheduling frequent follow-up visits to cheer successes, problem solve, or both
- Showing caring and concern for patients
5. Health behavior change consultations (HBCCs)
Complementary to other SDoH interventions, using health behavior change consultations has shown that a collaborative-team approach can address social needs.
A study of a medical student-led free clinic in Lake County, Illinois, offered health behavior change consultations (HBCCs) as part of a team approach to addressing social needs. Beginning with a referral from primary care, an inter-professional team evaluates the behavioral health, medicine, and pharmacy aspects of a patient's health.
An HBCC includes shared decision making around areas to address, identifying motivations and barriers to change, and goal setting. Discussion includes cultural factors and social determinants of health that impact the patient's ability and capacity to act. Once the HBCC plan is created, check-in sessions are combined with primary care appointments to assess progress and work through barriers. The program has shown that a collaborative HBCC approach can support positive change.
6. Equipping physicians and medical practices to support change
The primary care or physician's office is a central hub for a portion of patient engagement and opportunities to identify and address unmet social needs that affect health. However, physicians often feel ill-equipped to bring up or support their patient's complex and intertwined health and social challenges.
In a study, more than 40% of patients reported that their family doctor was unaware of their struggles with insufficient food, unreliable transportation to office visits, or inability to afford their medicines. One provider reported being aware his patient was an adjunct professor. The assumption was that the professor was healthy and successful because she was an educated professional. Yet, her unexplained weight loss was due to her inability to afford nutritious food on a low salary. The physician realized that a systemic approach is necessary where personal biases don't get in the way of transparency and inquiry.
Another physician's story confirms the need for standardized, systematic approaches. The doctor shared that the social needs screening for “one of her long-time patients was particularly eye-opening." The patient and her husband had lost their residence and were forced to move into a motel. They couldn't afford her insulin as well as motel and storage costs, which caused a dangerous sugar spike and a visit to the emergency room. Once the physician knew the situation, she was able to identify resources and ways that she and her clinic could help. Geared explicitly toward physician practices, the AMA STEPS Forward™ toolkit provides 8 steps to help clinicians and their staff improve assessing and addressing patients' SDoH needs.
7. Building structured, standardized, and integrated interventions
Payer, provider, and community organizations must partner and also pilot strategies to determine which interventions work best. Allina Health is an example of how SDoH screening, referrals, and follow-through can impact individual patients and the community. As 1 of 28 bridge organizations, Allina used CMMI funding over 5 years to determine “whether addressing patients' social needs reduced total health costs and care use and improved beneficiary and provider experience." Their program was so successful that it will be extended to all patients at its 10 hospitals and 80+ primary care and urgent clinics in Minnesota and Wisconsin in 2023.
Close the gaps, then close the loop
Identifying, addressing, and resolving social needs is complex and multi-faceted. Ideally, any standardized SDoH program uncovers needs and also supports patients in navigating available resources while ensuring follow-up to meet those needs. Closing the gaps or barriers to filling a need is one thing, but, as a clinician put it, “navigating to nowhere" requires partnerships and processes to refer to and track the patient's progress.
RTI Health Advance creates evidence-based, standardized approaches to SDoH interventions
Our healthcare experts span all the areas needed to create an evidence-based, standardized approach to addressing social needs. From the local social inequity score generated by our RTI Rarity™ tool, to health equity and population health program development, to data science and analysis to reveal best practices, we're here to help. Contact us.