We have written for several years about the importance of addressing the social determinants of health, which have attracted a national spotlight during the pandemic. Social determinants of health are the conditions in which people are born, grow, live, work and age; and they play a large role in determining health status and disparities, as seen with COVID-19. But as health providers receive funding to address them, how can they make sure the programming actually has the intended impact? Theory can help healthcare providers receiving this money—and any organization looking to implement social determinant strategies—develop successful programming.
In particular, the key challenge facing providers is the fact that they must expand it beyond traditional medical care in order to positively influence the social determinants of their patients’ health, whether it be through community partnerships or actually providing social services within a health clinic. This raises a host of new questions. Which new, specific activities should a provider take on? Should they build out those capabilities themselves or facilitate a handoff to another provider of social services? How can the provider ensure that social needs are actually being met and that their work in that area is having an impact?
In short, healthcare providers need a framework for how to think about the nuts and bolts decisions in the uncharted waters of addressing the social determinants of health.
Integration and Modularity
Modularity Theory describes how different parts of a complex system’s architecture relate to one another and consequently affect its level of performance. For any given activity, an organization must decide whether they want to perform that activity themselves (what we call integrate), or outsource by building a modular system in which someone else provides that service.
The place where any two components fit together is called an interface, and interfaces can either be well-defined and predictable or poorly defined leading to uneven processes. When the interface between two adjacent steps in a process or system is not well defined, Modularity Theory tells us that integration works best. A modular system is appropriate only when interfaces are so well-defined that the resulting processes are far more predictable and consistently produce the desired outcome.
To illustrate, consider the difference in the treatment of complex illnesses versus ear infections. With rare, complex illnesses, the patient’s needs can be unpredictable and widely varying. Hospitals integrate multiple specialties under one roof in order to control all types of care that a patient may need at any given time, and to ensure that care is both high-quality and provided in a timely manner. Diagnosis and treatment of complex care both happen within the hospital.
On the other end of the spectrum, ear infections are well understood, enabling predictable and standardized diagnosis and treatment. Whereas care for these types of conditions used to be handled in the hospital or primary care office, diagnosis has now been outsourced to places like MinuteClinic, where patients can receive a prescription and then treat themselves at home.
What does this mean for treating the social determinants of health? At present, treatment is a relatively new practice; many programs are still discovering for themselves how various social conditions like literacy and housing affect health, and what the best practices are for meeting social needs. This means that for healthcare systems to adequately address social determinants of health, they need to integrate across the interface between traditional healthcare providers and social services. Below, we outline a few reasons why some level of integration, at this stage of addressing social needs, is crucial.
1. With a completely modular interface, health professionals can’t control health outcomes.
Because the relationship between the delivery of medical care and the delivery of social care is not yet well defined, increased integration is required to obtain the necessary control and visibility into social determinants. Arms-length relationships with no coordination or follow-up do not allow providers to measure and drive impact.
But integration exists on a spectrum—it’s not all or nothing. Hospitals and physicians’ offices do not need to become full-fledged social service providers so long as they coordinate closely with outside parties and follow-up to ensure positive outcomes. If a doctor makes a referral for a patient experiencing housing insecurity to seek housing assistance, but does not have any processes for follow-up, there is no way to ensure that a patient sought housing assistance, let alone that it improved their health status.
2. By taking the reins of this problem themselves, healthcare providers can lead the charge for making meaningful change when it comes to social determinants.
The relationship between social determinants and health status is widely researched and well-established. Despite that, it was only recently that discussion of taking steps to combat social determinants came to the forefront of healthcare. Integrating some level of social services into their work will allow providers to better understand how access to social services impacts patient health outcomes in real time.
3. The connection between health and social needs is constantly evolving.
Particularly for patients with complex health and social needs, solving one set of problems does not automatically solve the other. And any solution might, unfortunately, only be temporary. Integrating medical and social services together allows both sectors to monitor the constantly changing status of their patients, and intervene when necessary.
Addressing the social determinants of health will go a long way in improving health across the country. But it will take the right type of programming to ensure social determinants are properly addressed in the healthcare space.