Social determinants are a critical component of our patients' health, affecting people in both tangible and insidious ways. The World Health Organization (2017) defines Social Determinants of Health (SDH) as those conditions in which people are born, grow, live, work, and age. Social Determinants of Health occur across dimensions of functioning (e.g., social, economic, and physical) and various environments and settings (e.g., schools, places of employment, religious centers, and neighborhoods) and affect the health, behavioral health, and general quality of life of populations (HealthyPeople.gov, 2017).
When reviewing risk factors that contribute to premature death, the numbers are astonishing and speak directly to the impact of SDH. Clinical care is said to be responsible for a surprisingly limited percentage of deaths, as little as 10% of the total. The majority percentage (40%) is due to individual behavioral factors (e.g., treatment adherence, acceptance of the need for treatment). Although 30% of the deaths are associated with individual genetics and genetic predisposition to illness, 20% are related to social and environmental factors (Schroeder, 2007).
To more specifically define what contributes to this 20%, let's look at the “list” of SDH. Also compare and note that these are what case managers have always evaluated when addressing our clients/patients/families. The availability of, and access to, any of the following social risk factors are particularly impactful to shaping the trajectory of patients' care:
- Safe and stable housing, including whether a patient can safely live alone, cope with any access challenges (e.g., stairs), maintain a clean environment, and afford housing.
- Public and personal safety, including whether there are any potential issues with abuse or whether community violence affects the individual's activities.
- Local emergency/health services.
- Transportation, including how individuals can access health providers, prescriptions, and food.
- Social interactions, including whether a patient lives alone or has connections with family and friends. It is well documented that loneliness contributes to health issues.
- Environments free of contaminated natural resources and/or life-threatening toxins (e.g., lead, waste).
- Access to food, including availability and affordability of nutritious foods in their communities and ability to prepare meals that support recovery.
This last bullet, food insecurity, has been identified as a most significant SDH, with many individuals having to choose between food and other health essentials. The following depicts the ranges of food insecurity (excerpt from Table 4, Fink-Samnick, 2018a):
High food security
- No reported indications of food access problems or limitations
Marginal food security
- One or two reported indications—typically anxiety over food sufficiency or shortage of food in the house
- Little or no indication of changes in diets or food intake
Low food security
- Reports of reduced quality, variety, or desirability of diet—little or no indication of reduced food intake
Very low food security
- Reports of multiple indications of disrupted eating patterns and reduced food intake
Adequately defining key client issues and opportunities for attention is more of a moving target than ever (Fink-Samnick, 2018b). And the means to best capture this knowledge have been an industry challenge. In striving to achieve successful outcomes, as lower readmissions and less costly care, teams strive to understand a wide lens of factors that impact a client's health. According to Fink-Samnick (2018), powerful assessment tools have been integrated in the latest electronic health record (EHR) platforms (p. 243). These tools assist case managers to more efficiently triage, screen, and assess client needs and ultimately connect them to critical resources.
In an effort to promote further work on standards for capturing social risk data in EHRs, many hospitals are now using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to record patient-level information related to social risk factors such as housing, literacy, and education (American Hospital Association, 2018). ICD-10 “Stress” codes are one avenue EHRs are collating these data. Although not specifically designated as SDH, there is a connection between these Z codes and the issues discussed earlier. ICD-10 Z “Stress” codes (ICD10Data.com, 2018) include:
- Z55 Problems related to education and literacy
- Z56 Problems related to employment and unemployment
- Z57 Occupational exposure to risk factors
- Z59 Problems related to housing and economic circumstances
- Z60 Problems related to social environment
- Z62 Problems related to upbringing
- Z63 Other problems related to primary support group, including family circumstances
- Z64 Problems related to certain psychosocial circumstances
- Z65 Problems related to other psychosocial circumstances
There are many SDH resources, of which this Editorial will only call out a few. Box 1 includes resources from the American Hospital Association on SDH. But I also call your attention to two other comprehensive resources:
- There is a significant section, titled “Successful Program Initiatives and Resources” (Fink-Samnick, 2018a)
- In PART II, peruse the section, titled “Insurance-Driven Partnerships and Initiatives” (Fink-Samnick, 2018b)
But SDH are not a constant construct; they continue to evolve, expanding in scope and impact for both populations and the case managers caring for them. Therefore, we will have a Guest Editorial in the next issue that will address the dynamic nature of the changing face of the SDH. Repeating the statistic earlier: Although 30% of the deaths are associated with individual genetics and genetic predisposition to illness, 20% are related to social and environmental factors. Case managers have intuitively always sensed this. It is why—sometimes against all odds—we continue to do what we do.
Fink-Samnick E. (2018a, May–June). Managing the Social Determinants of Health: Part I Fundamental knowledge for professional case management
. Professional Case Management
, 23(3), 107–129.
Fink-Samnick E. (2018b, September–October). Managing the Social Determinants of Health: Part II Leveraging assessment toward comprehensive case management
. Professional Case Management
, 23(5), 240–255.
Schroeder S. A. (2007). Shattuck lecture. We can do better improving the health of the American people. The New England Journal of Medicine, 357, 1221–1228.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
case management; ICD-10 Z “Stress” codes; Social Determinants of Health (SDH)