Prioritizing SDOH for Patients Living with Chronic Diseases: Compassion, Coordination and Community

social determinants of health,social determinants of health,

As a collective healthcare system here in the U.S., we have mostly embraced the knowledge that social determinants of health (SDOH), such as dietary patterns, housing security, transportation barriers, social isolation, comfort with communicating in English, health literacy, and more, play an enormous role in the development and outcomes of diabetes and other chronic diseases.

But we haven’t yet figured out what to do about it. As the U.S. healthcare system works to focus on the move to preventive, personalized care for patients, it’s time to turn the tide on diabetes by addressing the three Cs of chronic disease care: compassion, coordination, and community.

Creating capacity for compassion during routine care visits

To start, provider organizations and their health plan partners can support overburdened clinicians by integrating social workers into care teams. Social workers are the bridge between the clinical and non-clinical environments, and they can complete many of the SDOH-related tasks that physicians and nurses don’t have time or knowledge to address themselves. This includes ensuring patients are using all their health plan benefits, connecting individuals with community support groups, and providing education to assist with healthy decision-making.

Health systems must also do more to evolve care team structures that focus on expanding clinical capacity, giving back more time for physicians and nurses to complete their routine patient care duties, while also making space for discussing SDOH concerns with patients.

The direct value to patients of creating space for SDOH-focused activities cannot be overestimated, either. For example, one patient with diabetes at the Miami VA was chronically late to his appointments and refused to schedule his visits earlier in the day. When finally asked why, he said he always slept until 2:00 p.m. so he could skip breakfast and lunch. That’s because he couldn’t afford to pay for more than one meal a day. If we had never asked the question, we may have written him off as a “problem patient,” instead of someone who needed immediate help with his food insecurity.

Teaching coordinated care to clinical students with a person-first focus

Medical and nursing schools must also take a larger role in preparing clinicians to engage in a collaborative care environment that prioritizes socioeconomically sensitive, empathetic care for people with diabetes and other chronic diseases. Often, new clinicians are expected to learn about SDOH at the residency level. In reality, that’s too late.

By introducing these relationships early in the educational process and creating structured guidance around how to leverage these interactions in the real world of patient care, providers can start their careers with the competencies to shape a more coordinated future for whole- person chronic care management.

We have found that one of the best practices is having students participate during dedicated education modules to better understand the factors that influence SDOH, and how to discuss these issues with patients in real-world settings. These modules are paired with interprofessional education (IPE) options to familiarize students with working alongside social workers, behavioral healthcare providers, podiatrists, nephrologists, and other specialties to deliver holistic care to people with diabetes.

Integrating community and cultural factors into whole-person care

Building up healthy and resilient communities requires providers to reach beyond the walls of the clinic and truly connect with organizations that influence daily habits and help prioritize healthy choices. These may include schools, faith-based groups, nonprofits, or veterans’ associations.

For example, the American Diabetes Association (ADA) recently partnered with the Elevance Health Foundation to enhance its What Can I Eat? (WCIE?) program: an in-person and virtual initiative to bring nutrition education, free healthy foods, and other resources directly to underserved communities in Indiana, New York, Ohio, and Virginia. The ADA is currently looking for more community-based partners in these regions to facilitate the in-person components of the program.

A renewed focus on empowering clinicians with social worker support so they have more time to focus on compassionate care; enabling stronger care collaboration as part of the medical education process; and powering a new, proactive approach to tapping into community assets will go a long way toward addressing the SDOH challenges being faced by many people today. Only then will people living with chronic diseases, like diabetes, have the chance to access the type of value-driven, equitable care that we all deserve in the 21st century.

Editor’s Note: Podimetrics, where Gary Rothenberg is director of medical affairs, has a strategic relationship with the American Diabetes Association as part of their collaboration in the Amputation Prevention Alliance.

Photo: vaeenma, Getty Images