In the last decade, US healthcare leaders have worked to increase medical coverage, decrease cost, and improve access to quality of care. These efforts have produced positive results, such as a reduction in readmissions and a decrease in medication errors, but the US remains an unhealthy country overall. In fact, if we use life expectancy at birth as a proxy measure of a population's health as offered by the World Health Organization (WHO), the US doesn't fare well.
A Peterson Center on Healthcare and Kaiser Family Foundation analysis of 2018 Organization for Economic Co-operation and Development (OECD) data demonstrated that US life expectancy at birth was growing at a slower rate than that of 12 comparable developed countries.1 As of 2016, the US had an average life expectancy of 78.6 years, the lowest of the 12 countries. The Peterson-Kaiser analysis also compared the measures of disease burden by calculating years of life lost due to premature death, as well as years of productive life lost to poor health or disability. In a country with the latest technology, sophisticated devices, and expert clinicians, Americans carry a higher disease burden than those living in comparable developed countries.2
The US also spends a disproportionate amount of money on healthcare. Americans spend over $3.5 trillion annually and more than $10,700 per person per year on healthcare and related expenses as compared with an average of $5,280 per person per year in comparable countries.3 In the US, 90% of healthcare dollars are spent on medical treatments that occur within a healthcare setting, such as a hospital or provider's office.4 However, up to 70% of a person's overall health is driven by social and environmental factors and the behaviors that influence them, which are external to the medical and healthcare environment.5 Other developed nations do a far better job of preventing suffering from serious illness by investing more in social services. From the OECD data, about $2 is spent on social services for every $1 of healthcare as compared with only about 55 cents for every dollar spent in the US.6 There must be a paradigm shift to providing services outside of the healthcare system if the US is to make real progress in improving patient outcomes and overall health.7
Improving health is about more than offering diagnostic and treatment services within the four walls where those services are provided. A patient's health is greatly dependent on what occurs between interactions with healthcare providers. Moreover, what occurs outside of the healthcare facility is dependent on a variety of factors known as social determinants of health (SDOH). This article discusses these factors and explores the role of the nurse leader and nurse informatician in incorporating SDOH into patient care.
Social determinants of health
Where you live, work, play, and pray influences your social determinants, which influence your health in turn. The potential health impacts of SDOH factors, such as education, economic concerns, food insecurity, housing instability, transportation shortages, environmental issues, interpersonal violence, immigration status, healthcare utilization, and overall health costs, are well documented. Analyses presented by multiple organizations found that overall health is attributed to the following factors: individual behavior (36%), social circumstances (24%), genetics and biology (22%), medical care (11%), and environment (7%).8
Landmark documents, such as a 2008 report by the WHO Commission on Social Determinants of Health, also provide evidence to demonstrate that income, education, social status, and social support are correlated with increased morbidity and premature mortality.9
Incorporating SDOH into patient care
It's clear that broader approaches need to be developed to reduce health costs and improve quality and outcomes in the US. Achieving these goals requires recognition of and response to the social, economic, and environmental factors that impact health. Nurse leaders and nurse informaticians need to understand the current evidence related to screening, risk assessment, data capture and transfer, community referral and follow-up, and evaluation of programs established to address SDOH factors.
It's important to remember that all nurses are ethically obligated to consider individuals and their health conditions within a framework of complex interactions of biological, emotional, cognitive, social, and environmental factors. Provision 8 of the American Nurses Association's Code of Ethics for Nurses directs the nurse to collaborate with other healthcare professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.10 The ethics code calls for nurses to be innovative in developing approaches that are ethical, respectful of human rights, and equitable in reducing health disparities.10 Addressing SDOH is called out in the foundational models of nursing care and within the mandate of nursing professional practice.
Whether in a care setting, the community, or academia, the nurse leader can prepare and mentor nurses to assume new roles to address SDOH. These motivated nurses will need to lead interprofessional, multiorganizational, and collaborative efforts to identify risk through screening; establish upstream and downstream service referral networks; provide training to other providers, patients, clients, and communities; and ensure that data and information are exchanged within and among the services interacting with targeted patients, clients, or communities. These nurses can act as change agents in the development of systems of care that address population health needs through management of SDOH. (See Using data to address food insecurity.)
This is so crucial that the Robert Wood Johnson Foundation commissioned The Future of Nursing 2020-2030 project, which will be accomplished through a consensus study conducted under the National Academy of Medicine. A key goal is to gain an understanding of how nurses can serve as change agents to achieve improved health within communities.12 The results, due in 2020, will provide important insights into preparation of nurses as they take on these emerging roles.
The nurse informatician will need to lead, collaborate, and support nurses taking on new and emerging roles in population health programs in which SDOH have a significant impact. Informatics nurse specialists (INSs) must lead efforts to consider the use of community- or individual-level data to describe and target SDOH while measuring achievement of specific quality outcomes. This will require the INSs to know informatics tools and techniques beyond the electronic health record screen build and data extraction. Developing knowledge and skills in the tools of data science, visual analytics, risk stratification, and predictive and prescriptive analytics will become essential. Understanding the nuances of using valid and reliable screening tools, as well as the appropriate targets of each tool, will be mandatory. Being engaged with SDOH tool comparisons, such as the Social Interventions Research and Evaluation Network, or SIREN, of the University of California, San Francisco, will also be important.
Informaticians should know how to extract and manipulate large, community-focused, open-access data files. Engaging in activities currently underway that are directed at data modeling, standardizing, and encoding SDOH data will be essential as informaticians lead interoperability efforts between healthcare providers and participating social services providers such as a local food bank, a mixed housing community center, or even a car-sharing service. Ensuring that SDOH concepts captured in screening tools, data elements, and value sets are coded within the Systematized Nomenclature of Medicine—Clinical Terms; Logical Observation Identifiers Names and Codes; International Classification of Diseases, 10th Revision; or Current Procedural Terminology will be essential. The INS may need to use Consolidated-Clinical Document Architecture to move data between service providers. Lastly, the INS may also need to be trained to use the Fast Healthcare Interoperability Resources specifications to build applications that can be used to seamlessly exchange data between health and social services providers.
Change for the better
Consideration of SDOH is necessary to achieve better population health through improved healthcare quality and access. Nurse leaders and informaticians must be able to incorporate SDOH into care activities. However, for nurses to take on leadership roles to drive this change, training, mentorship, and new models must be established.
Using data to address food insecurity11
Grenier and Wynn describe how concerned nurses within the Rush University health system in Chicago, Ill., launched the Rush Surplus Project to address food insecurity within the community. The nurses initially used data tools to identify food insecurity as a key SDOH that impacted their population of at-risk patients and drove poor outcomes. The project aimed to repackage and distribute unused food from the healthcare facility to those in need, which required collaboration with area nonprofit leaders, community organizations, and the healthcare facility. These nurses pushed themselves to use data to identify a population need and drive change beyond their facility in a way that positively improved health outcomes.
1. Peterson-Kaiser Health System Tracker. How does US life expectancy compare to other countries? 2019. www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries
2. Peterson-Kaiser Health System Tracker. What do we know about the burden of disease in the US? 2017. www.healthsystemtracker.org/chart-collection/know-burden-disease-u-s
3. Peterson-Kaiser Health System Tracker. How does health spending in the US compare to other countries? 2018. www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries
4. Peterson-Kaiser Health System Tracker. How has US spending on healthcare changed over time? 2018. www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time
5. Peterson-Kaiser Health System Tracker. What do we know about social determinants of health in the US and comparable countries? 2017. www.healthsystemtracker.org/chart-collection/know-social-determinants-health-u-s-comparable-countries
6. Davis K. To lower the cost of healthcare, invest in social services. Health Affairs
Blog. 2015. www.healthaffairs.org/do/10.1377/hblog20150714.049322/full
7. Bradley EH, Taylor LA. The American Health Care Paradox: Why Spending More Is Getting Us Less
. New York, NY: PublicAffairs; 2013.
8. Cho E, Sonin J. Determinants of health. Goinvo. 2017. www.goinvo.com/vision/determinants-of-health
9. World Health Organization Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. 2008. https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf
10. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements
. 2nd ed. Washington, DC: American Nurses Association; 2015.
11. Grenier J, Wynn N. A nurse-led intervention to address food insecurity in Chicago. Online J Issues Nurs
12. National Academies of Sciences, Engineering, and Medicine. The future of nursing 2020-2030. www.nationalacademies.org/hmd/Activities/Workforce/futureofnursing2030.aspx