Achieving Health Equity Starts with Social Determinants of Health

Sandy Garcia, RN, BSN, MBA, NHA, CJCP
Sandy Garcia, RN, BSN, MBA, NHA, CJCP
Associate Vice President Regulatory Affairs and Behavioral Health Services

At this time, the Joint Commission is the most prescriptive accrediting body and has placed new healthcare disparity requirements into the hospital and critical access manuals and the ambulatory and behavioral health manuals, effective January 1, 2023. All other accrediting bodies, including DNV and HFAP plan to follow suit. The Centers for Medicare and Medicaid Services already have published material addressing health equity.    

Specifically, the Joint Commission’s requirements are: 

  1. The [organization] designates an individual(s) to lead activities to reduce healthcare disparities for the organization’s patients. 
  2. The [organization] assesses the patient’s health-related social needs and provides information about community resources and support services. 
  3. The [organization] identifies healthcare disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients.  
  4. The [organization] develops a written action plan that describes how it will address at least one of the healthcare disparities identified in its patient population. 
  5. The [organization] acts when it does not achieve or sustain the goal(s) in its action plan to reduce healthcare disparities. 
  6. At least annually, the [organization] informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified healthcare disparities. 

Healthcare disparities are often viewed through the lens of the social injustice, they are first a quality of care problem for organizations.   

Addressing social determinants of health is a beginning but remember that health equity is a very long journey.   

Without a doubt, social determinants of health (SDoH) are a hot topic in healthcare. That’s for good reason.   

  • Health outcomes: Research suggests medical care accounts for only 10-20 percent of health outcomes while the other 80-90 percent are attributed to demographic, environmental and socioeconomic factors.  
  • SDoH prevalence: 68 percent of surveyed patients have had at least one social determinant of health challenge; 57 percent have a moderate-to-high risk for financial insecurity, isolation, housing insecurity, transportation, food insecurity and/or health literacy.  

The vast majority of health outcomes are attributed to social determinants of health such as demographic, environmental and socioeconomic factors.

By all accounts, the COVID-19 pandemic has exacerbated social determinant challenges. For example, the Census Bureau’s March 2-14, 2022 Household Pulse Survey, which was designed to quickly compile data about how people’s lives have been impacted by the pandemic, found

  • More than 1 in 8 adults reported they or someone in their household had experienced a loss of employment income in the past four weeks. 
  • More than six in ten adults reported at least a little difficulty paying for usual household expenses in the past week, and nearly 32 percent used credit cards or loans to meet household spending needs.  
  • Seven percent of adults had no confidence in their ability to make next month’s housing payment, and 10+ percent reported food insufficiency. 
  • Nearly one in three adults reported symptoms of depression or anxiety.  

A study in the fall of 2021, Assessment of Strategies Used in US Hospitals to Address Social Needs During the COVID-19 Pandemic, revealed “hospitals are integrating screenings to assess patients’ social determinants of health, but programs and community partnerships to address SDoH have been slower to develop.” 

Among 4,295 hospitals, 64 percent reported strategies for three areas: 

  • Screening for nine SDoH types. 
  • Creating programs or interventions to address those. 
  • Collaborating with community partners to mitigate SDoH, participating in community health needs assessments (CHNA) or implementing SDoH initiatives. 

How Hospitals Are Addressing Health Disparities 

 Returning to the Joint Commission requirements, below is additional information and questions to get started. 

  • Identifying an individual to lead activities to reduce healthcare
    Who will that be in your organization? A chief equity officer, a case manager, a social worker, an inpatient nurse, an outpatient nurse or a physician. 
  • Assessing the patient’s health-related social needs
    What are the components of the assessment?
    How to assess those components?
    Who will assess those components?
    What will you do with this information? 
  • Analyzing quality and safety data to identify disparities

Using stratified quality data strategically allows healthcare organizations to:  

  1. Discover and prioritize differences in care, outcomes and/or experiences across patient groups. 
  2. Plan equity-focused care transformations and measure impact. 
  3. Tell the story of how patients experience healthcare. This brief is organized into these three topics and recommends strategies that healthcare organizations can use to effectively organize and interpret stratified quality data to improve health equity for their patients. It is intended for healthcare organizations and collaboratives that already have quality data stratified by one or more demographic variables.  

  • Developing an action plan to reduce healthcare disparities
    Healthcare organizations are advised to stratify quality measures that reflect organizational priorities and that would be most sensitive to disparities. These can include measures of access and care delivery, e.g., missed appointments or immunization rates, clinical outcomes, satisfaction, cost or others. Because managing data can be time and resource intensive, organizations can reduce this burden by choosing measures that overlap with quality improvement work they are already pursuing, e.g., patient-centered medical home certification or require federal, state or health plan reporting. Ideally, data should also be easy to collect or readily available through sources such as registries, electronic health records, medical charts, claims data, health plan/payer or state data files. Organization also may want to prioritize domains of care expected to differ the most across demographic groups.
  • Taking action when the organization does not meet the goals in their action plans
  • SMART goals are specific, measurable, attainable, relevant and timely.
  • Informing key stakeholders about progress to reduce healthcare disparities
    Who are your key stakeholders that you will inform?
    What will you inform them of or what data will you provide?
    How often will you inform your identified key stakeholders? 

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