Addressing SDOH to Reduce Health Disparities

70% of a patient’s long term wellness is determined by factors outside hospital walls, which means that addressing social determinants of health (SDOH) is vital to the success of a patient’s overall health. Social determinants of health are the social and economic factors that contribute to an individual’s health, which include factors such as income, access to healthy food, quality of education, family support, and more. These factors can have a profound impact on one’s health and contribute to health disparities in our society. Addressing SDOH is a critical step to reducing inequity in the health of patients.

What are health disparities?

Health disparities are differences or gaps in the quality of health or health care between different groups of people. They can result for a variety of reasons including race, gender, income, education level, disabilities, and more. A health disparity refers to a higher burden of illness, injury, or mortality in one group when compared to another. There are also health care disparities that exist in the quality of care or access to care for patients.

Why is addressing health disparities important?

Addressing health disparities among the population is important for a variety of reasons. First and foremost, addressing health disparities is important to providing health equity across the population. Every individual deserves the quality of care that is necessary for them to be healthy. Addressing health disparities works toward improving overall population health. Health disparities are also extremely costly to society. An estimated 93 billion dollars are spent each year on excess medical costs due to disparities. Race is a common influencer of disparities, and people of color are estimated to make up 52% of the population in 2050. Keeping that in mind, as our population becomes more and more diverse, it is increasingly important to address these disparities. 

Examples of health disparities 

Many health disparities can be connected to race. For example, African Americans have an infant mortality rate that is almost twice the national average, and in 2017 12.6% of African American children were reported to have asthma compared to that of 7.7% for non-Hispanic white children. The maternal mortality rate is also 3 times higher for African American women than white women in the US.

In regards to COVID-19 in the US, minority groups are being affected at an alarmingly higher rate, with a death rate 3 times higher than white Americans. Minority groups are also less likely to be insured. 16.1% of Hispanics and 14.9% of American Indians were uninsured in 2017 compared to 5.9% for non-Hispanic whites. Income level is also a contributing factor for likeliness to be insured. In 2018, individuals with a higher income were 4 times more likely to be insured. Gender has been known to impact mental health among individuals, with men having a higher suicide rate, while women are more likely to have depression.

Closing the gap 

Because these health disparities are so prominent in this country, it is crucial to work towards closing the gap. Reducing health disparities starts with addressing SDOH. Achieving health equity is reliant on being aware of the needs and requirements of an individual and realizing that special attention may be required for at risk populations. It is important for both health care providers and community based organizations to collaborate to help reduce the barriers that cause these disparities. Acknowledging and identifying that factors such as family support, race, income, education levels, etc. are a contributing factor toward the quality of care and long term wellness of individuals is necessary to being able to work toward solving the issue of health disparities.

The partnership between health systems and community based organizations helps to address social determinants of health by closing the loop. Community based organizations exist to provide resources to help those in need. The extra help received from these organizations is oftentimes necessary for vulnerable patients to achieve long term wellness. Acknowledging the social and economic factors that are contributing to a patient's health is the first step toward addressing SDOH. The next step is being able to direct them to the resources they need to address these issues. This is where a strong referral network comes in. A strong network of resources allows a doctor to direct patients to the extra help that they may need. It also helps nonprofit organizations refer clients to other organizations that offer other needed services in the community.

How community organizations help break down barriers

Community organizations work toward breaking down barriers that reduce health disparities by providing access to resources such as food, housing, transportation, education, and more. These resources are key to addressing social needs. For example, without stable transportation, an individual is unable to make it to a follow up appointment that may be necessary toward achieving long term wellness.

While we know that there is no immediate solution to solving these barriers, every amount of support these organizations provide is impactful. Big changes can start with seemingly small steps. From a transportation nonprofit providing a ride to a job interview to a clothing shelter supplying the coat a child needs to stay warm in the winter, these resources matter and have the ability to change lives.

How technology helps address SDOH

Sometimes it can be difficult to screen for SDOH. Some patients may be unwilling to answer questions verbally about social or economic issues that they may be facing. This is where technology comes in to help. With the help of artificial intelligence (AI), chatbots can be used to ask questions to patients to screen for SDOH. This AI tool can scale to be used to serve more people than traditional teams alone, reducing manual effort. When individuals are recognized as having SDOH that need to be addressed, it is important that these people are able to be directed to and made aware of the resources available to them. This is where an effective case management and referral platform comes in. Pieces Connect is a cloud-based software that helps health care providers and nonprofit organizations manage their cases and make referrals. It helps reduce manual efforts of case workers and has an 82% closed loop referral rate, which means that information was provided from the organization about the outcome of the referral. Closed loop referrals allow the referral sender to know whether or not the referral was completed. Pieces Connect makes it easy to make referrals and help people get the extra help that they need.

Another great way technology helps address SDOH is through natural language processing (NLP) and AI. Pieces Predict is a cloud-based software that, with the help of NLP and AI, hospitals can use to read clinical notes and extract valuable information about SDOH. This assists clinicians in being able to more easily recognize socially-vulnerable patients and better allocate resources to those who need it most. 

Addressing SDOH to reduce health disparities is important to improving lives and the health of communities. Technology helps bridge some of the gaps and increases efficiency when addressing SDOH.