"Are The Social Determinants Of Health 'Mission Creep?'"
So asks this piece from Dr. Chuck Dinerstein published by the American Council on Science and Health. The quick answer to Dr Dinerstein's question is "yes, definitely, and that's a good thing." But a deeper reflection on the questions raised in the piece is worth the time.
For some time, the healthcare community has been conflicted about SDOH. On the one hand, the idea that social factors affect health outcomes and costs makes intuitive sense to clinicians and the social sector alike, prompting excitement and optimism about their potential for achieving positive outcomes. On the other hand, social determinants feel "squishy," ill-defined, and less "real" than many clinicians are comfortable with, especially in a data-driven era of randomized double blind placebo control drug trials.
In his article, Dr Dinerstein puts it this way, with reference to SDOH initiatives: overwhelmingly "thought leaders believe that the possible improvement in patient outcomes and satisfaction is worth the effort" but that "data on the impact ... is currently in short supply." This view reflects several important (but understandable) fallacies in SDOH thinking.
The first fallacy: social interventions are comparable to clinical interventions
Clinicians understandably expect healthcare interventions to deliver widespread consistent and statistically relevant results to be considered legitimate. After all, human bodies are generally similar, barring certain genetic and personal variances: a medical intervention that works well on a sample group should work equally well in a general population. By the same logic, a social intervention that 'works' in one place should deliver the same result when applied, shouldn't it? As Dr Dinerstein puts it, "While our gut tells us that these factors are essential, you might expect some proven benefit before committing funds and further upending our concept of healthcare."
In point of fact, there is a plethora of data that SDOH initiatives can have positive impacts on both health outcomes and costs. What there isn't is consistent data that the same intervention works everywhere.
This basis of this fallacy is the assumption that social interventions must be uniform, consistent, and predictable, and that they must work consistently in all social environments. Barring those rules, says the clinician, the outcome of any SDOH initiative is illegitimate, subjective or just 'not scientific.'
People from the social services world (not to mention common sense) will tell you that expecting clinically-reliable results from the messy real world we live in is unlikely. A social intervention that works fantastically well in Camden, New Jersey in the winter may yield radically different results in New Orleans, Louisiana in summer. After all, the climate, the institutions,m and the culture are all different, all resulting in different human behavior ... which is precisely the thesis of SDOH. When pockets of data show positive outcomes in different contexts, the social sector celebrates while the clinician concludes that there is no evidence of success.
[As a side note, the businessperson would also view this scenario positively. Scalable businesses are based on the idea of repeatable formulae, but always allow for the customization of products and operations to different market conditions. McDonalds serves ramen in Hawaii and the McShrimp burger in Russia and Japan. The business world takes it for granted that markets are messy and difficult to predict, especially new ones.]
The second fallacy: the healthcare system must drive and manage social interventions
In his article, Dr Dinerstein points out that while 71 % of respondents to a NEJM survey agreed that scaled-up SDOH initiatives will happen over the next three to five years, "this view is mainly supported by the executives who will manage these new initiatives and not the clinicians who will be tasked with doing the assessments, care coordination, and necessary follow-up." Dinerstein correctly points out that "clinicians are clear that ... the actual work of changing a patient's social determinants is not their job" but seems to imply that unless they do so, addressing social determinants won't occur.
The assumption underlying this assumption is that no one else is either able or willing to engage in delivering social interventions outside the healthcare community. In point of fact, the greatest number of successful SDOH interventions are delivered by non-healthcare specialists in partnership with clinicians. In fact, social service organizations address social issues every day and have been doing so without the oversight of the healthcare system for some time. Further, the organizations most successfully initiating and delivering SDOH interventions today are not led by healthcare institutions but by coalitions and partnerships crossing the spectrum. To be fair, achieving such collaborations is not easy (especially at scale), and the healthcare industry could be forgiven for wondering how such a thing may come about without reproducing their expertise and models. But the data clearly points to the idea that SDOH interventions operated by the healthcare system do far less well than those respecting the independence and expertise of the social sphere.
The third fallacy: the current lack of SDOH coordination is a permanent condition
Dr. Dinerstein's article references a survey published in the NEJM about attitudes towards SDOH. Here is a chart of the survey results to which he refers:
Dr Dinerstein concludes from these results that "there are no resources to screen and evaluate patient needs." While a "lack of effective screening tools" is one of the issues cited by respondents to the NEJM survey, 84% of respondents didn't consider it to be of primary importance. In fact many excellent SDOH screening assessments exist, with some (like the PRAPARE) rapidly rising to ubiquity. The number of tools and blueprints not just for evaluating social needs but addressing them (like the Pathways Community Hub and Activate Care's FLEX Blueprints) is increasing steadily.
Dr Dinerstein correctly points out that the most important challenge facing respondents is "a lack of resources and coordination with community organizations to meet those needs once identified." This is absolutely correct. But the truth - and what the respondents clearly believe - is that this is a solvable condition rather than a permanent state.
SDOH initiatives and community collaboration do in fact work, and are improving at a breakneck pace. Over the past few years, the innovation and creativity of people within and outside healthcare - whose "gut tells [them] that these factors are essential" - have designed and deployed SDOH collaboration and intervention systems with positive results and are iterating them in positive directions every day. While the questions Dr Dinerstein raises about SDOH initiatives are excellent and logical from a certain point of view, the SDOH genie is out of the bottle and it isn't going to be stuffed back in.