An overview of Health-Related Social Needs 

A large body of research shows that social factors like income, education, and neighborhood safety have a significant impact on our health, before we even step foot in a doctors’ office. Over the past two decades, clinicians and public health practitioners have increased their focus on upstream, preventative measures to address these social determinants of health. 

Health-related social needs (HRSN) can result from adverse social determinants. For example, having a low income may hinder someone from being able to delead the paint in their house, despite it causing them immediate health issues. Targeting this specific HRSN would be an effective way to improve the patient’s health and prevent further health concerns down the road. In a situation like this, deleading the patient’s home is health care. 

CMS supports HRSN screening

Many healthcare centers are already screening patients for HRSN, and the Centers for Medicare & Medicaid Services (CMS) will include HRSN screening as one of its key quality measures. In January, CMS outlined how states can be creative in using Medicaid-managed care plans to offer services targeting HRSN. Four states (Arizona, Arkansas, Massachusetts, and Oregon) have arranged for Medicaid coverage of rent/temporary housing for high-need individuals, and a recently approved California proposal allows for medically tailored meals, asthma remediation, and sobering centers as well. Creativity is encouraged if it means providing high-need individuals with the support that will keep them healthy.

On its face, this is beneficial. If clinicians can screen and identify HRSN, and if they can connect their patients with easy, effective assistance, the overall health of our population is likely to improve. However, HRSN screening can be detrimental if not approached with care.

HRSN screening: Proceed, but approach with caution

Healthcare guidance and support can only be effective if the patient trusts their care team. Unfortunately, American medicine has a spotty record of being trustworthy in certain communities. From the Tuskegee experiment to mistakenly reporting parents to social services to reporting abortion patients to the police, there are many reasons patients may trust their healthcare teams and may not want to self-report their HRSN. 

Take pediatric HRSN screening, for example. A recent JAMA Viewpoint by Arvin Garg, MD, MPH; Alison LeBlanc, MS, PMP; and Jean L. Raphael, MD, MPH lays out why this screening isn’t necessarily welcomed by all parents.

Despite parental support for HRSN screening and an opportunity for parents to connect and receive support from their pediatrician, there is also great concern particularly from low-income minoritized parents. Their concerns include feelings of shame, being judged and discriminated against by the health care team, fear that disclosing needs will lead to filings with child protective services and removal of their children, and frustration with disclosing sensitive needs without getting acknowledgment and help.

Arvin Garg, MD, MPH; Alison LeBlanc, MS, PMP; and Jean L. Raphael, MD, MPH in JAMA Viewpoint

This doesn’t mean that HRSN screening should be completely scrapped, but it should be developed and implemented with care and caution. 

The authors of the JAMA Viewpoint identify a few ways to ensure equitable and empathetic HRSN screening. Their recommendations include:

• Let the patient lead. If the patient chooses not to seek assistance for social needs, that decision must be respected.
• Incentivizing health systems to partner with patients in addressing their HRSN
• Shifting from screening for social risk (identifying adverse social factors in patients’ lives) towards social needs (asking about an individual’s priorities and perceptions of what they need) 
• Training hospital staff on unconscious bias and cultural humility so as to not cause further harm
• Collaborating with patients, staff, and community members to design social care support programs
• Advocating for a stronger social safety net. Ultimately, social policies will be needed to address HRSN. Health systems, staff, and patients alike should not hesitate to advocate voraciously for those policies.

Patience and persistence are also needed to overcome challenges in the long term. For example, the CMS evaluation report of their Accountable Health Communities Model found that while food insecurity was the most prevalent and persistent HRSN and beneficiaries with food needs were the most likely to use community services, this HRSN was unlikely to be fully resolved during the three year time period. This is indicative of the challenge of addressing unmet social needs in the long term; these problems did not appear overnight, nor will they be fixed overnight.

For HRSN screening to be effective, it requires trust between patient and provider. Kaiser Permanente found that something as simple as explaining why screening questions are being asked and how that information may be used has an impact on a patient’s willingness to divulge. Referral services should also be evaluated to ensure patients are provided with effective services in a timely manner; after all, screening is not particularly useful if nothing is done with the results. 

Regulatory bodies that set the standards for healthcare facilities can help by incentivizing health systems to adopt HRSN screening and solutions. The January 2023 guidance from CMS is a great starting point as it allows states to customize their services based on specific needs. 

When we approach it with humility and empathy, HRSN screening can be impactful. Addressing health-related social needs can be an effective way to quickly improve the health and life conditions of patients, and we should continue to push for progress in this area.

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This past January, Florida’s department of education rejected course materials and topics for a new AP African American Studies course, writing to the College Board that the subject matter “significantly lacks educational value.” This has concerning implications for the next generation’s understanding of the world around them – and how they conceptualize the impacts of social determinants of health, bioethics, and the history of this country.

Black History and Health

Why is learning Black history in the US necessary for our nation’s health? Closing racial health gaps is a key concern, but we don’t give our health professionals the historical context they need to do the best job of closing these gaps. Myths about physiological differences based on race (such as Black people feel less pain or have worse lung function) were created centuries ago to justify slavery and discrimination. But some of these myths are still present in the medical community, furthering unequal care. 

The de facto segregation in hospitals also needs a historical context to be understood and dismantled by medical educators, clinicians, and hospital leaders alike. In the AMA Journal of Ethics, Dr. Emily Cleveland Manchanda and colleagues explain how current segregation in medicine stems from our history of racist policies like redlining, exclusionary zoning, and the bifurcation of publicly and privately insured patients. Without knowing the history, Manchanda et al. write, it’s easy for the medical system to assume that segregation is normal, and to keep the cycle going.

And as medical schools strive to include more students from underrepresented backgrounds, we need to have an understanding of the policies that led to the closure of most Black medical schools in the 1900s.  

Queer Studies and Intersectionality are also Black History

Two of the target topics rejected by the Florida Department of Education were queer studies and intersectionality. “Intersectionality” was coined by Kimberlé Crenshaw over 30 years ago as a way to conceptualize and describe the various ways a person’s social identities, like race, gender, and class, overlap. Examining the world through this lens allows for a more complete, nuanced understanding of how these determinants play out in a person’s life. By cutting the reading requirements of queer and feminist scholars, this move is an attempt to sever the connection between queer studies, intersectionality, and Black history. But these are not, and never have been, fully separate topics.

Consider the gay rights movement, for example. The Stonewall Riots are largely seen as the catalyst for the movement. The most prominent figure and activist from the Stonewall Riots is Marsha P. Johnson, a Black gay and transgender rights advocate who herself had experienced the impacts of intersectional marginalization. She was on the front lines of the Riots, galvanizing a nationwide fight for equality. 

Discrimination, especially as experienced by Black trans and gender non-conforming individuals, has an impact on both short- and long-term health. A well-known example is the AIDS crisis, in which homophobia both from the government and community members isolated LGBTQ+ individuals and treated them as disease vectors, not people. Activists have fought the dual damage of racism and homophobia for decades. Even today, Black Americans count for 40% of the 1.2 million Americans living with HIV despite only constituting 12% of the nationwide population.

The impacts of intersectional marginalization are still obvious in our society today. There is an ongoing public health crisis of violence against Black transgender and gender non-conforming individuals. It is impossible to conceptualize this crisis without having a foundational understanding of the history of harm these groups have endured.

There is no understanding the gay rights movement without understanding the intersection of race, sexuality, and gender, and how that affected individuals’ lived experiences. To exclude even one is to have only partial comprehension.

Looking at our healthcare system, it’s easy to see how racism is baked into the structures and policies to create disparate outcomes. Acknowledging the systemic nature of racism is the first step toward reaching the equitable system of health we all want and need — we should embrace it, not fear it.

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Black Americans face a disproportionate amount of gun violence

According to Everytown, a nonprofit advocating for gun control, Black Americans are disproportionately subjected to gun violence. The statistics are astounding: with ten times the gun homicides as compared to white Americans, eighteen times the gun injuries, and three times the fatal police shootings, Black Americans face a horrific threat of gun violence. 

Apart from the obvious trauma inflicted by guns, firearm violence deteriorates the wellbeing of entire communities. The constant threat compounds an individual’s cumulative stress load, leading to chronic health conditions even if one isn’t directly victimized by gun violence. The problem intensifies in historically underfunded cities, correlating with deep inequities in resources, support, and economic instability. 

It gets even trickier when considering mental health – over half of suicides in the United States involved a gun, and the vast majority who attempt suicide with a gun are successful in their attempt. Suicide rates, specifically amongst young Black men, are on the rise, leading some experts to posit that higher rates of gun ownership are connected to higher rates of self-inflicted gun violence.

Hospital staff get traumatized too

It can feel like we are in a never-ending cycle of firearm trauma. From Tyre Nichols to the six mass shootings in California just last month, it can feel endless. The damage ranges from mass shootings to domestic violence to self-harm to police brutality, and it doesn’t just impact victims and their families. Hospital staff are subjected to devastating cases time and time again, especially staff who work in emergency departments in metro areas. 

Seeing so many cases of needless gun violence takes a toll. Depression, PTSD, and anxiety can all emerge from repeatedly treating victims and having hard conversations with their families. Quickly moving on to the next patient feels empty of empathy yet is expected. Hospital staff are struggling more than ever and repeated instances of gun violence can be triggering – especially for Black staff who feel the extra burden of racialized gun and police violence.  Black hospital workers may feel the impacts even deeper when working with Black victims. It’s traumatizing to try and save a gun or police violence victim with the knowledge that you personally belong to the group being targeted.

Just ask our Board member Dr. Selwyn O. Rogers, Jr., M.D., M.P.H., a surgeon, public health expert, and founding director of  the University of Chicago Trauma Center. In an article published in NEJM last month, Dr. Rogers describes the trauma he carries from treating victims of gun violence day after day.

“In reality, I harbor and carry the burden of suffering within me. The piercing screams, the severed limbs, the brain matter exuding from the temporal lobes haunt me. Many evenings on the drive home, I know that my inner battery is spent, that I have no more strength to shoulder the hurt. I have nothing left to give. Sometimes when I get home, I cry like a baby on my wife’s shoulder. My wife, my three sons, my friends, and my faith — a belief in things not seen — recharge me.”

From Grief to Hope

While the nation continues to cycle through gun violence-related grief, healthcare workers are still standing up for their patients and communities. People in healthcare can leverage their unique knowledge and experience to advocate for gun control and police reform as they continue to heal victims. In recent years, clinicians have been stepping up and speaking out about firearm violence, declaring “This is our lane.” Collective power, especially from a highly trained and vital workforce like that of healthcare, is the way forward. 

Just as recovery after violence provides hope in the ER, recovery from our social conditions is possible and can provide hope for a better future. As Dr. Rogers wrote in his NEJM piece, “Despite the uncountable victims, the howls of pain, the repeated sadness, such moments give me hope — hope that if such a patient can recover and find joy and communion, perhaps someday our society can too.”

Do you know a clinician leading the way in preventing firearm violence? Nominate them for a BLASR!

The post How firearm trauma impacts hospital staff appeared first on Lown Institute.

In a Health Affairs Grantwatch blog, Shannon Brownlee and Vikas Saini from the Lown Institute and Benjamin F. Miller from Well Being Trust discuss how state budgets are being squeezed by health care costs and what we can do about it. 

“According to a 2018 projection from the Government Accountability Office (GAO), states will face a “fiscal gap,” driven largely by rising health care expenditures. Health care expenditures are effectively crowding out states’ discretionary capacity to invest in non–health care or social determinants of health. These expenditures include spending on Medicaid and health insurance benefits for state employees and retirees.”

A report from the Lown Institute, supported by Well Being Trust, on California’s budget spending found that spending on health care grew by 146 percent between 2007 and 2018. During that same period, spending on community conditions increased by just 39 percent. Many other states in the same bind; according to a 2018 Government Accountability Office (GAO) report, state spending on health care as a percentage of gross domestic product is predicted to double between 2008 and 2067, while non–health care expenditures are expected to decline by 50 percent.

While rising health care costs are a hot topic in politics, state legislators and policymakers often do not see health care and social spending as connected. “Rarely is the topic of excessive health care spending framed as an opportunity cost, which limits states’ ability to provide other services that can have an even larger impact on population health,” write Brownlee et al. 

This framing issue is not just a California problem; most Americans view access to health insurance as the most important driver of health. We have to convince policymakers and the public that community conditions matter for health just as much as insurance coverage, that “allowing health care costs to continue to rise faster than the rest of the economy not only affects their pocketbooks but also their overall health.”

Read the full piece in Health Affairs Grantwatch!

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Here are our key takeaways from the meeting:

We need better data on health and social needs

Health and social needs vary considerably from community to community, but health data is not always detailed enough to capture these differences.

As CEO of the Asian & Pacific Islander American Health Forum Kathy Ko Chin explained, the uninsured rate of Asian-Americans as a whole is quite low. However, when you look at the rate of coverage for each specific nationality, there are significant disparities; Koreans, Bangladeshi, and Pakastani Americans have much higher rates of uninsurance, because they have a greater proportion of small business owners. Without this knowledge, policymakers may wrongly assume that Asian-Americans are covered, and that no more outreach needs to be done in these communities. In this way, the inability to disaggregate data perpetuates the “Model Minority” myth, said Chin.

The problem of demographic differences not captured in health data is not only an issue for national data collection. Alva Ferdinand, assistant professor of health policy and management at the Texas A&M School of Health and expert on rural health, pointed out that the community health needs assessments (CHNA) that hospitals are required to conduct often take a broad view at community health issues, but do not drill down into the needs of sub-populations in that community. These “umbrella CHNAs” often miss specific needs of rural communities such as food and housing security, and health literacy, missing opportunities for positive change in these areas. Further, using the same population health targets for rural and urban areas may not be realistic or achievable, said Ferdinand.

Examining the systems that create social inequities is key

There is broad agreement among health care policymakers and researchers that community conditions greatly impact health. But we rarely examine the reasons why disparities in social factors exist in the first place, said Linda Goler Blount, CEO of Black Women’s Health Imperative. “Disparities exist because they’re rooted in historical systems of oppression,” said Blount. Identifying white supremacy as a cause of health disparities should be a prerequisite for health care institutions moving into the “social determinants space.”

The impact of racial discrimination on the health of Black women is profound. The stress caused by racism can raise  cortisol levels and cause inflammatory responses, putting Black women at an increased risk of obesity and maternal mortality. Going upstream in addressing health issues for Black women means tackling racism. 

Shola Olatoye, NYU visiting fellow and former CEO of the New York City Housing Authority, agreed: “We can’t have a conversation about the social determinants of health without talking about racism and white supremacy.” Implementing community health programs while ignoring systemic racism and oppression will only put a band-aid on the problem. However, the role of discriminatory policy in creating and perpetuating disparities is not always acknowledged.

For example, data gathered from the Drivers of Health interactive game found that most people attribute health care access to government policy (ie. Expanding insurance coverage), but far fewer attribute social factors such as education and income to historical government policies. Understanding how government policy created residential segregation and perpetuates income/wealth inequalities on racial lines is key to reversing health disparities.

Researchers and policymakers should use a “community-first” approach

Health policymakers and researchers value detailed quantitative health data– and rightly so. However, qualitative data can be just as important when researching community conditions, said Ferdinand. “When I was a graduate student, I heard from economists that ‘our job isn’t to talk to people.’ But through my work I realized just how important it is to do exactly that.”

Harold Pollack, professor at the University of Chicago School of Social Services, concurred. He recalled a needle exchange program that received pushback because they hadn’t elicited community feedback before implementing the program. 

Knowing what to ask when eliciting stakeholder feedback is just as important. We shouldn’t be coming to community members with a program and asking them how to implement it, said Blount. Rather, “We should be asking community members, ‘What do you need?'”

Balancing health system and community organization involvement is a challenge

Improvements in community conditions are desperately needed throughout the nation, but are hospitals and health plans the right entities to provide social services? Maybe not, panelists said, but health care is where the money is. 

“The health care system is left holding the bag because our social services and policy levers aren’t doing the job,” said Pollack. “We don’t really have a choice. We have to learn how to do it through the health care system because no one else will do it.” 

Health care systems moving into the social program space can create opportunities for positive change. Olatoye pointed out that working on social issues is an educational opportunity for young clinicians and trainees, who may not have considered the health impact of social factors before. 

However, the panelists were also concerned about the “medicalization of social services.” What the health care sector might see as progress in provision of social services may lead to harm in practice. For example, hospitals would fight food insecurity by sending meals to people’s houses via drones, said Betsey Tilson, State Health Director and Chief Medical Officer of the North Carolina Department of Health and Human Services. But then you would lose the social interaction of Meals on Wheels, negating an important part of the program. “Health care likes the shiny objects but it’s really people to people that matters,” said Tilson.

Further, if the health care system is duplicating efforts of social programs, that is a poor use of resources. “If it’s all done by health care it’s bad, if it’s all community-based organizations it’s bad. There need to be partnerships” said Gary Sing, Director of Delivery System Investment and Social Services Integration at MassHealth.

Beyond referral: What’s next for community conditions?

The panelists discussed ways in which the power of health care institutions and government policy could be harnessed to improve community conditions. However, there are also numerous ways in which hospitals and clinics can transform themselves to reduce health disparities, such as being more welcoming to patients of all races and ethnicities, building trust with patients before screening for social needs, and putting less of a burden on patients to accessing and paying for health care. 

As health care institutions are increasingly held accountable for improving community conditions, they should also be tasked with looking inward and making sure their discrimination policies and financial assistance policies are not actively harming patients. 

The post Experts discuss what communities need for health appeared first on Lown Institute.

Previous studies have shown that income fluctuations, without savings to buffer these swings, can lead to debt, financial insecurity, and stress. Now, new research is showing that income volatility may have an impact on heart health as well. Earlier this year, a study in Circulation found that sudden income dips in early adulthood are associated with a nearly two-fold increase in risk of cardiovascular disease and all-cause mortality. 

In a recent study in JAMA, a team of cardiologists and public health researchers found that individuals whose households experienced a 50% drop in income over 6 years were 17% more likely to have a cardiovascular incident (heart attack, heart failure, or stroke) compared to those with a stable income. On the other hand, individuals whose households experienced a rise in income over that time period were 14% less likely to have a cardiovascular incident.

These findings make sense, given that income volatility has been shown to increase stress, which can negatively impact heart health. Unfortunately, this can create a vicious cycle, because the cost of treating health care problems can create more financial problems. These studies add to the large base of evidence showing that financial difficulties, including those caused by the high cost of health care, contribute to poor health. 

Social programs designed to provide income support can positively impact health even more if they help stabilize household incomes and provide buffers for income downswings. For example, unemployment insurance should be more easily accessible to all workers, when people are experiencing income drops after unemployment. The positive health effects of the Earned Income Tax Credit could be boosted by giving people the option to get monthly payments rather than annual, and increasing the amount of the monthly credit. 

Clinicians should also be aware of the negative impact of income downturns on health and be able to refer patients to income support in their community, if possible. Clinicians should also be sure to consider the cost of care when helping patients make treatment decisions.

“We don’t often think about the social factors that can contribute to cardiovascular health. It’s a different way of thinking that we as cardiologists are not used to,” said Dr. Scott D. Solomon, a professor of medicine at Brigham and Women’s Hospital and senior author of the JAMA paper, in The New York Times.

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Many students have welcomed these changes, but some doctors perceive these changes as medical schools “stepping out of their lane.” Dr. Stanley Goldfarb, former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine, recently wrote a controversial op-ed in the Wall Street Journal lamenting the advancement of social justice issues in medical school “at the expense of rigorous training in medical science.”

Is it true that the broadening of medical education from “pure” science to social science really damaging for the medical field? Despite Goldfarb’s assertion that social issues only “tangentially” affect healthy, a growing body of research on community conditions has shown the critical links between factors like income, housing, neighborhood safety, and education and long-term health outcomes. Understanding these links and advocating for improvements in community conditions that affect health is an important part of caring for patients. Organizing for better community conditions can also be empowering for clinicians, in a system where clinicians often feel helpless to fix the socioeconomic forces harming their patients on a daily basis.

Goldfarb’s piece created an uproar in response, especially from UPenn students, faculty, and alumni. UPenn faculty members responded in the Philadelphia Inquirer, citing disparities in maternal mortality, the Flint water crisis, and other examples of social issues that directly affect health. “Separating social justice from medicine deprives students of the opportunity to apply concepts into clinical practice and sends the message that these issues are independent rather than intertwined,” wrote Dr. Crystal Zheng and other UPenn Alumni in Medscape. 

Dr. Bernard Lown is another example of a doctor who saw the value in tackling social issues for health. In the 1980s Lown co-founded, with Dr. Yevgeny Chazov from the Soviet Union, International Physicians for the Prevention of Nuclear War (IPPNW). They pointed out that nuclear detonation would have a devastating impact on the health of humanity, and were recognized for their work with a Nobel Peace Prize.

As for Goldfarb’s argument that teaching social justice is not leaving enough time to teach “how to cure patients,” many doctors have pointed out that the “bloat” in medical education is not from adding social issues, but from rote memorization on scientific topics (like the Krebs Cycle) that students will never use in their clinical practice.

Can someone explain to me why I had to memorize the Krebs cycle in medical school but never learned about surrogate endpoints and how they are used in trials that affect clinical practice? @VinayPrasadMD @adamcifu pic.twitter.com/kmO0Ww7dzb

— Roxana Daneshjou, MD/PhD (@RoxanaDaneshjou) July 7, 2018

In fact, many doctors have argued that recent changes in medical school curricula have not gone far enough. As Dr. Liyang Pan at University College London Hospitals Foundation Trust writes in a BMJ opinion piece, medical education for her was too focused on rote memorization and getting the “right answer,” rather than understanding the meaning behind the answers.

“Students, myself included, use a combination of acronyms and memory aids rather than understanding that guidelines are recommendations or questioning their underlying evidence,” Pan writes.

This deficiency in understanding often leads to harm, when clinicians follow “one-size-fits-all” guidelines that recommend drug treatments as the first line of therapy. Ironically, the emphasis in medical education on biology, neuroscience, and other basic science topics leads students (and later, doctors) to care more about how a medical intervention works, rather than whether it works at all, writes Dr. Vinay Prasad at Oregon Health and Science University. Prasad and Dr. Adam Cifu at the University of Chicago present an alternative medical curriculum, which emphasizes the clinical encounter and evidence-based medicine rather than basic science topics.

In our book @adamcifu and I spend a couple chapters re-designing the curriculum from ground up, and these days I play around with a figure more like this.https://t.co/mGWg1Ky1F1 pic.twitter.com/hFLQmkWFaB

— Vinay Prasad 2.0 (@VPrasadMDMPH) July 8, 2018

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Many of these startups promise improved health through increased access to testing (such as blood testing or genetic sequencing), monitoring (constant tracking of steps and heart rate, for example), and personalized care (such as health and nutrition plans based on genetics). However, the evidence that these functions improve health is slim, the authors write. Genomic sequencing has not been shown to improve population health or change health behaviors; wearable fitness trackers don’t actually help people lose weight; and personalized health plans rarely give people information about diet and exercise they don’t already know. 

The promise of health from these startups is based on the assumption that focusing on individual behavior is the answer. However, they ignore that individual health habits themselves are “affected by a set of socioeconomic factors, which together with environmental conditions affect how long we live, our mental well-being, and a host of other health outcomes.” 

Brownlee, Saini, and Miller conclude, “If Silicon Valley really wants to disrupt the health care sector in a way that has the most impact on people’s health, it needs to bake an understanding of community conditions into whatever ideas they put forward.” 

Read the full op-ed here, and the Lown Institute report on California’s spending on community conditions!

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Despite the substantial increase in health care spending, millions of Californians continue to suffer from chronic health care problems, high infant mortality rates, and lower life expectancy, brought on by toxic air and water pollutants, poverty, food deserts, lack of affordable housing, and low levels of formal education. Ironically, more spending on health care is eating up California’s budget, making it more difficult for policymakers to allocate needed spending for community conditions.

The Lown Institute report stresses the importance of rebalancing state budgets by reducing health care waste and investing in community conditions. Improving public education, increasing financial security, building spaces for people to exercise safely, and providing more affordable housing not only have proven health benefits, they also pay for themselves many times over through fewer hospitalizations and emergency room visits.

Despite the health and financial benefits of investing in community conditions, it is often difficult for organizations that provide social services to secure funding for vital community conditions. One solution is to partner with health care institutions on these investments, since health care institutions benefit from having healthier patients. 

The Commonwealth Fund recently released a new tool to encourage these partnerships between social services providers and health care institutions, by giving them an estimate on how much they could save by investing in community conditions. The Return on Investment (ROI) Calculator, developed by Dr. Victor Tabbush of UCLA and based on work conducted by the SCAN Foundation, “allows organizations to learn how their social needs investment might pay off in terms of cost savings and changes in the amount of health care complex patients use.”

To use the calculator, you’ll need some key information about which social service investments to measure, which health outcomes do you expect to change by investing in social services, the current utilization rates and costs of these services, and the number of people that would benefit from new investments in social services. Some average numbers can be found on the Commonwealth Fund website, but all fields can be tailored to the service that your or your partner organization want to provide.

The tool calculates the cost of each service per beneficiary and then calculates the savings to the health sector for investing in community conditions. Their calculations come from a wealth of research on the returns on investment for social spending, a summary of which the Commonwealth Fund has also made available on their website.

Understanding how much communities have to gain from investments in community conditions, both in improved health and decreased spending from health care utilization, is important for creating more partnerships between health care systems and community benefit organizations. The ROI calculator tool is a potential game-changer for establishing the potential benefits of social investments — with this much to gain, we can’t afford not to spend more on community conditions.

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However, there are many other ways in which health care institutions can address social determinants of health beyond screening and referral. At an event organized by MLPB, a medical-legal partnership organization that addresses health-related social needs in New England, health care leaders shared how they are improving access to both health and social services at their institutions. Here are a few of our takeaways:

Create a welcoming environment

When patients walk through the door of a clinic or hospital, their first impression can affect their experience going forward. For Whitman-Walker Health, a federally qualified health center in Washington, DC, specializing in LGBT care, creating a comfortable environment was crucial for building relationships with patients, said Erin Loubier, Senior Director for Health and Legal Integration at Whitman-Walker. Whitman-Walker remodeled their space, turning it from a dark and foreboding waiting area to one full of light. They also made sure all restrooms were gender-neutral and that staff name tags included their pronouns, so that patients would feel comfortable no matter their gender identity.

At Stanford Children’s Health, which serves families of various immigration statuses, putting up signs reading “All are welcome” in different languages was a simple step to build trust with families, said Dr. Baraka Floyd, Clinical Assistant Professor at the Stanford School of Medicine. 

Prioritize patients’ needs 

One of the most important ways that health care institutions can serve people in their community is by finding out the most pressing need for people in their community and providing this need. For example, Whitman-Walker Health started offering legal services to change identity documents for people undergoing a gender transition, which brought in many new patients who also had health needs to address. By identifying their patients’ most important need, Whitman-Walker Health engaged patients who otherwise would not have come to the clinic, said Loubier.

Build trust before screening for social determinants

Asking patients questions about their economic and housing needs is a new process at most health care institutions, and can bring up issues that are difficult to talk about. That’s why it’s important to explain the reasons behind the screening before asking sensitive questions, said Floyd. Clinicians should be screening not just for risk factors but also protective factors — what economic, educational, and social assets do patients have that can provide resources? Learning about patients’ strengths can help clinicians prioritize their social needs and create a plan that utilizes these strengths.

Rethink “patient compliance”

Patients are often asked to do a lot by health care systems, not all of which fit in with their daily lives. For example, appointments may require taking time off work, securing childcare and transportation, which is not always feasible for patients. Then, patients may be blamed for being “non-compliant,”  which can strain relationships between clinicians and patients.

Dr. Dannie Ritchie, Founder of Community Health Innovations of Rhode Island, asserted that we need a reframing of the issue of “patient compliance.” We have to recognize that patients have many competing priorities, so health care organizations have to work toward helping patients’ basic needs. Again, creating a welcoming environment is key. “Why would someone make an appointment to go to a hostile place?” said Ritchie.

In Floyd’s experience, teaching medical students to go beyond the one-dimensional model of “adherent vs non-adherent” is critical. She tries to get physicians to ask, “What is the barrier that’s making it difficult for this patient to adhere to a certain treatment?” Then, they can address the underlying issues, not just put a band-aid on them. 

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