There is increasing recognition that the provision of traditional healthcare services may contribute less than previously thought to health outcomes. Other factors such as patient demographics, socio-economic status, housing, employment, and behavioral histories such as early childhood traumas may have profound and lasting impact on a patient’s health. Recently, the Institute of Medicine recommended capture of these factors into electronic health records.

These new domains of information capture and management pose significant challenges to the busy primary care physician already consumed by daily practice with the panoply of ailments confronted by primary care providers. In the most recent issue of the Annals of Family Medicine, there are presented two articles representing point and counterpoint to this argument. This blog summarizes these two sides.

The Argument for Primary Care to Take on Social Determinants of Health

New incentive programs to improve the value of healthcare that is being delivered demand that new models of care are innovated that incorporate the expanded management of key factors that directly or indirectly contribute to health outcomes in patients.

New models of care that incorporate expansion of the role of teams including social work, nurse case managers, behavioral specialists and others will facilitate the identification and management of the social determinants of health.

Health disparities has long been known as not only health outcomes that represent gaps for specific populations, but also as a target for intervention. The Accreditation Council for Graduate Medical Education (ACGME), the body that sets the standards for medical training, has recently called out health disparities as needed targets for training and improvement in care.

The Argument against Primary Care to Take on Social Determinants of Health

Primary care physicians are already overworked. Burn-out and depression are rampant among both young and old primary care clinicians. In comparison to primary care systems of earlier decades, this generation of primary care physicians needs to not only diagnose and treat the myriad acute health problems that walk through the door each day, but also to assess and manage all the preventive health needs of their patients, as well as the confounding mental and behavioral conditions that accompany patients.

Moreover, primary care physicians in particular, are also being asked to radically improve, streamline, and make more efficient the nuts and bolts of their work. This transformative work is in addition to the growing clinical demand. There is the reality of opportunity cost of doing both transformative work, social determinant work and an increasing complex load of clinical work. Will the latter suffer, as we add the first two to the busy clinicians plate?

Finally, the evidence is limited on how effective primary care clinicians are or could be in managing the array of social determinants of health that are affecting their patients.

 An Approach to Integrating Social Determinants into Primary Care Practice

There are three cardinal steps to bring social determinants into your clinical practice. First, you need to be able to access and/or collect both population level and individual level data about the social determinants affecting your patients’ lives. Data from public health data sources, community assessments can be paired with asking specific questions are defined by the Institute of Medicine in their recent report¹.

Second, you need to integrate this data, both population and individual, into your workflow at both encounter levels as well as panel management levels. For instance, is it important to know that the patient with diabetes you are trying to titrate their insulin dosages also is homeless with an experience of trauma in their life histories?

Third and finally, you need to be able to link this dynamic set of social determinant/ clinical data to effective interventions and support. These include referrals to social services, other medical specialists, patient engagement programs, and coordination of services, both clinical and social.

1. Institute of Medicine. Capturing Social and Behavioral Domains in Electronic Health Records. National Academies Press, 2014