PAs and Social Determinants of Health: 4 Things to Know

Integrating SDOH Into Care Can Lead to Better Outcomes and Adherence

June 30, 2020

By AAPA Research Department

Social determinants of health (SDOH) are the “conditions in which people are born, grow, live, work and age as well as the complex, interrelated social structures and economic systems that shape these conditions.”¹ SDOH can be separated into three distinct areas where health may be impacted: social environment, physical environment, and access to health services. SDOH not only are associated with health outcomes but may also impact treatment options PAs choose when managing and treating patients.² Understanding patient personal and environmental factors and insecurities may help PAs to make necessary adjustments to treatment plans and to direct patients towards the appropriate community resources and services. Learn more by registering for our next free Diversity, Equity, and Inclusion CME Webinar, The Role of Social Determinants of Health in Clinical Practice and Subsequent Health Outcomes.

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Here are four important things to know about SDOH.

1. SDOH are associated with health outcomes.

SDOH disproportionately affect patients who are racial minorities. SDOH are directly related to healthcare delivery and management, with lower income communities having a larger share of the disease burden and a disproportionately higher share of poor health outcomes.³  Between 1935 and 2016, persons in rural communities had a ten-year shorter life expectancy than the U.S. overall; African-Americans have the lowest life-expectancy of all ethnicities in the United States.⁴ This has been recently illustrated with COVID-19 exposure and infection. Across the U.S., death rates from COVID-19 show that 61.6 per 100,000 African Americans die compared to 28.5 per 100,000 white Americans; similar findings are true for indigenous persons (43.2) as well.⁵

2. Most PAs report that they review some social determinants before assessing a patient.

In May 2019, AAPA surveyed PAs on whether or not they regularly ask new and existing patients about a variety of social determinants of health, including things related to race, ethnicity, sexual orientation, gender identity, socioeconomic and housing factors, employment and education, and other things such as safety, domestic violence, social support and stress. Seven in 10 PAs (70.8%) report that they are “likely to,” “usually,” or “always” review any social determinants before assessing a patient. Almost three in five (57.8%) report updating SDOH data for an individual patient during most or every visit.

Providers who integrate their patients’ differences into their health plans act as health advocates and are valuable resources for their communities. Understanding social determinants of health with treatment creates a greater holistic approach to health that may benefit patients in the long-term. ⁶ Considering patient access to healthcare, pharmacological services, and ability to pay for medications or insurance while treating and managing patients are several ways that providers can promote health equity in the community.²

Providers and patients can face multiple challenges related to SDOH. Inquiring about SDOH can be stressful to the PA and to the patient. PAs are often unsure of the best methods to acquire this information and lack the time necessary to address a patient’s SODH in conjunction with their primary visit.⁵ Common barriers that PAs face to reviewing SDOH at every visit include lack of time, unavailability of referral services,⁷ and provider perceptions of electronic health records fragmenting patient data.⁸

3. PAs are more likely to use SDOH in treatment when educated.

Education about social determinants of health make it more likely practitioners will inquire about them and use the information to treat patients. Recently-published research demonstrated that after completing a charting CME called Outside the Box, PAs significantly improved their frequency of inquiring about and utilizing SDOH in patient treatment across each of five domains: (1) race/ethnicity, (2) sexual orientation/gender identity, (3) literacy (including numeracy), (4) physical, sensory, or cognitive disabilities, and (5) economic and geographic factors. Not only were the improvements statistically significant, but the magnitude of the differences was moderate to large in all cases except economic and logistics.⁹

4. There are tools to help PAs integrate SDOH into every visit.

Both the National Association of Community Health Centers (NACHC), and the Agency for Healthcare Research and Quality provide training, survey methods for practices to use, and data supporting the use of SDOH collection. The NACHC tool, PRAPARE, Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences, is a national effort to better prepare and assist providers in collecting and applying data they need to better understand their patients’ SDOH. PRAPARE provides ways to standardize the social assessment tool and address the concerns flagged in the assessment with their patients’ transforming the care patients are receiving and building stronger provider-patient connections.

Conclusion
Increasing awareness of patient SDOH increases overall investment in equity in patient care. Understanding and addressing issues underlying SDOH are directly correlated with higher patient and community health outcomes. PAs who integrate SDOH into their routine patient care see higher patient satisfaction with care, greater health outcomes, and greater patient adherence to medical advice. ^10,11

About the data
Data were collected in May and June 2019 as part of the AAPA PA Practice Survey.

Authors are Kristina Medlock, BA, AAPA Research Intern, and Timothy C. McCall, PhD, associate director of surveys and analysis. Contact them at [email protected].

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More Resources
Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
Agency for Healthcare Research and quality: SDOH & Practice Improvement

References

1. NCHHSTP Social Determinants of Health. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/nchhstp/socialdeterminants/index.html. Updated December 19, 2019. Accessed June 3, 2020.
2. NEJM Catalyst. Social Determinants of Health (SDOH). NEJM Catalyst. December 1, 2017. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0312. Accessed June 5, 2020.
3. Baah FO, Teitelman AM, Riegel B. Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review. Nurs Inq. 2019; 26(1):e12268. doi:10.1111/nin.12268.
4. Singh GK, Daus GP, Allender M, et al. Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016. Int J MCH AIDS. 2017; 6(2):139-164. doi:10.21106/ijma.236.
5. APM Research Lab Staff. The Color of Coronavirus: COVID-19 Deaths by Rave and Ethnicity in the U.S. https://www.apmresearchlab.org/covid/deaths-by-race. Updated June 24, 2020. Accessed June 22, 2020.
6. Andermann A. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ Podcasts. 2016. DOI:10.1503/cmaj.160177.
7. Girgis L, Van Gurp G, Zakus D, Andermann A. Physician experiences and barriers to addressing the social determinants of health in the Eastern Mediterranean Region: a qualitative research study. BMC Health Serv Res. 2018; 2018(614). DOI: 10.1186/s12913-018-3408-z.
8. Gold R, Bunce A, Cowburn S, et al. Adoption of social determinants of health EHR tools by community health centers. Ann Fam Med. 2018; 16(5):399-407. doi: 10.1370/afm.2275.
9. Zuber K, McCall TC, Bruessow D, Devine PJ, Straker HO. Improving health disparities in PA practices. JAAPA. 202; 33(1):33-38. 10.1097/01.JAA.0000615488.54560.3a.
10. COVID-19 FAQs: Health equity in a pandemic. American Medical Association Web site. https://www.ama-assn.org/delivering-care/health-equity/covid-19-faqs-health-equity-pandemic. Updated April 16, 2020. Accessed June 10, 2020.
11. American Academy of Physician Assistants. Charting CME on Health Disparities Leads to Positive Changes in PA Practice. https://www.aapa.org/news-central/2020/01/charting-cme-on-health-disparities-leads-to-positive-changes-in-pa-practice/. January 21, 2020. Accessed June 10, 2020.