What are social determinants of health? Aging providers and the next generation
Welcome to the September edition of Tips and Topics (TNT). My heartfelt thanks to the many readers who took the time to write and share their support and feelings about the August all-SOUL edition
This month in SAVVY, the focus is on social determinants of health.
In SKILLS, it is important to assess and include social determinants in treatment planning, not as an afterthought or “discharge planning” task.
In SOUL, a guest contributor asks “how do we capture our faith, skills and experiences in order to share and pass them along to the next generations of professionals?”
We often think that good outcomes in healthcare depend a lot on finding the best practitioner who can make the most accurate diagnoses and then devise the best practices and treatments to take care of the health problem. But increasingly there is evidence for the importance of social factors in determining the health of individuals.
Identify what you know about social determinants of health
“Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes. These conditions are known as social determinants of health (SDOH).”
The CDC goes onto say:
“We know that poverty limits access to healthy foods and safe neighborhoods and that more education is a predictor of better health. We also know that differences in health are striking in communities with poor SDOH such as unstable housing, low income, unsafe neighborhoods, or substandard education. By applying what we know about SDOH, we can not only improve individual and population health but also advance health equity.”
There are five major SDOHs:
- Food Insecurity
- Housing Instability
- Utility Needs e.g., electricity, sanitation, heating, and cooling
- Transportation Needs
- Interpersonal Violence
Most providers don’t screen for social determinants of health – What about You?
Social risk screening is important because it’s increasingly recognized that social risks are linked to poorer treatment adherence, worse health outcomes and higher costs of care.
In a September 18, 2019 paper
in the Journal of the American Medical Association (JAMA) “most U.S. physician practices and hospitals are screening patients for at least one social need, but only a small percentage are screening for all five social needs recommended by the federal government.”
Screening for interpersonal violence was the most common, while checking patients for utility needs was the least common.
1. Taressa K. Fraze, PhD; Amanda L. Brewster, PhD; Valerie A. Lewis, PhD; et al: “Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals” JAMA Netw Open. 2019;2(9):e1911514. doi:10.1001/jamanetworkopen.2019.11514
2. Harris Meyer: “Most providers don’t screen for social determinants of health” Modern Healthcare September 18, 2019.
Review how the ASAM Criteria’s Dimension 6, Recovery Environment, includes social determinants of health
In many ways, the ASAM Criteria was ahead of its time, because we started working on Dimension 6, Recovery Environment in the 1980s.
Dimension 6: Recovery/Living Environment explores an individual’s recovery or living situation, and the surrounding people, places and things. It focuses on assessing how supportive a person’s current environment is to recovery.
Dimension 6 assesses the need for services specific to:
- Individualized family or significant other therapy
Since social determinants of health (SDOH) affect treatment adherence, health costs and outcomes, it is time to broaden our skills to screen for and address SDOHs.
Assessing Dimension 6 and social determinants of health is an initial priority not a discharge planning activity
Too often family and significant other work is postponed until family week or weekend; or a family group that is not well promoted to families and then is poorly attended with little effectiveness.
Or housing, work and transportation needs are considered discharge planning items that can wait while “real” treatment is done.
Assessment considerations in Dimension 6 include:
* Do any family members, significant others, living situations, or school or work situations pose a threat to the person’s safety or engagement in treatment?
* Does the individual have supportive friendships, financial resources, or educational or vocational resources that can increase the likelihood of successful recovery?
* Are there legal, vocational, regulatory (e.g., professional licensure), social service agency or criminal justice mandates that may enhance the person’s motivation for engagement in treatment if indicated?
* Are there transportation, child care, housing or employment issues that need to be clarified and addressed?
The ASAM Criteria (2013) pp 52-53
Advocate for and develop more community supports and housing options as urgent clinical and systems priorities
With the opioid crisis and a heightened awareness and funding for more addiction treatment services, there is a tendency to see more residential beds as the solution. But this raises problems:
- Many treatment providers are still using residential levels of care in a program-driven manner with phases that require clients to remain in an initial treatment phase characterized by removal of cell phones, restricted contact with the outside world etc. for a certain period of time. These limitations are usually not assessment and clinically-driven, but program-design driven.
- Because of Dimension 6, Recovery Environment social problems of homelessness and toxic living companions, many clients can’t easily transition out of residential levels due to a shortage of affordable housing, recovery residences, supportive living environments and/or funding for these community resources.
- The result of poor housing and living supports, coupled with a program-driven design of services is waiting lists; decreased access to care; and inefficient use of resources.
The bottom line is that I have proposed that we don’t need more residential beds, we need:
- More community supports for severe addiction clients – assertive community teams (ACT) and intensive care management (ICM) similar to what good severe mental illness care management has.
- More living options from wet, damp and dry housing options; Housing First models; boarding rooms, recovery residences, safe shelters, group homes, Oxford Houses, shared rental units etc.
- Early intervention and community outreach around SDOHs at the front end of the addiction treatment continuum and ACT and ICM teams as integral parts of the service continuum that can directly address SDOHs as well as clinical needs.
A new report from a consensus committee
of the National Academies of Sciences, Engineering, and Medicine provides recommendations to guide practice and policy discussions in this area. The recommendations of this consensus committee report reflect the importance of social factors in determining the health of individuals and the need to recognize the broader environment in which health systems operate.
Kirsten Bibbins-Domingo, PhD, MD, MAS: “Integrating Social Care Into the Delivery of Health Care”
JAMA. Published online September 25, 2019. doi:10.1001/jama.2019.15603
A colleague and friend, Thomas A. Peltz, LMHC, CAS, M.Ed. has worked in the mental health field as both a counselor and an administrator since 1973. He is very familiar with hospital, residential, withdrawal management, outpatient treatment and partial hospital program levels of care. With that long experience, Tom asked if I might consider tackling the aspect of ‘aging providers in the field?’
So I invited him to speak his mind on that. Here is his contribution to SOUL:
“A quick Google search shows (although not professional, AA started in 1935), National Institute on Alcohol Abuse and Alcoholism (NIAAA) started in 1970, National Institute on Drug Abuse (NIDA) in 1974, and the Substance Abuse and Mental Health Services Administration (SAMHSA) started in 1992. Clearly this field of addiction treatment is relatively new – professionally speaking, however I simply don’t see much on the topic of aging providers.
There are so many things that growing older in this field has offered – such as:
- ‘Forgetting more than I have learned’ as one staff person use to say
- Working with people who might be using different drug or behaviors which I as the professional have little personal knowledge about
- Slowing down in some things like electronic media skills while maturing in wisdom and skills in other clinical areas and becoming seasoned enough (perhaps) to be able to teach or supervise newer staff
- Seeing the coming and going of programs/insurance mandates/treatment models/ government legislations/staff/patients and so on and on which all make my head spin
- Experiencing too much suffering including patient death after death after death causing compassion fatigue while on the other hand having the wonderful opportunity to witness the amazing miracles of sobriety and healing both in individuals and families
- Still having payment battles for reimbursements and
- The joy of seeing younger staff enter the field.
Staff in the field are getting older. I wonder specifically:
- How we deal with retiring and with ending our working careers?
- Some of us might just cash out with full Social Security benefits.
- Others might end when physical health demands it.
- Do we just stop updating our resume?
A friend recently read me a sentence from the prologue of the book We Know How This Ends: Living While Dying Bruce H. Kramer and Cathy Wurzer (Univ. Of Minnesota Press; April 1, 2015). It goes: “… legacy is an act of ego, while teaching is an act of faith.”
My SOUL question to your readers is how do we capture our faith, skills and experiences in order to share and pass them along to the next generations of professionals?
I would hope that we offer to teach what we have learned to the next group of providers entering into this most rewarding and most difficult line of work.”
Thomas A. Peltz, M.Ed.
Beverly Farms, MA 01915-0520
Thanks, Tom for getting those of us who are winding down our careers to think about how to harness “our faith, skills and experiences” for the good of those just starting out.