Managing Population Health

A patient’s health can be determined by genetics, lifestyle, and other factors specific to that patient. Other determinants, however, may become more significant factors for that patient and for the population of patients that share similar determinants. These social determinants of health contribute to the patients’ adverse and complex health conditions, such as obesity, heart disease, and diabetes.

Social determinants of health (SDOH), as defined in a recent NEJM article, are “intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.”

The Centers for Disease Control and Prevention (CDC) indicates that “differences in health are striking in communities with poor SDOH such as unstable housing, low income, unsafe neighborhoods, or substandard education.” A 2018 consumer survey “that 68% of consumers had at least some level of SDOH challenges. The most commonly reported issues are financial insecurity and social isolation. Individuals with high social determinants of health stress are 50% more likely to suffer from chronic conditions and 2.3 times more likely to rate their health as ‘fair’ or ‘poor.’”

For the primary care physician, social determinants of health can impact decisions made for population health management, in particular regarding treatment plans, prescriptions, and even nutritional recommendations. The physician must take into consideration whether patients can afford to eat healthy foods, fill their prescriptions, and follow other plans of care that may be out of their range either financially or logistically.

As suggested by Healthcare IT News, “As a better picture can be painted about patient populations, clinicians can better target populations who may be in need of additional services. These small upfront costs can help reduce the need for more major and costly treatment later on.” When the primary care physician develops a more in-depth understanding of the circumstances that patients experience, including such factors as whether they have access to transportation or whether they experience food insecurity, the provider will be better equipped to “find easy-to-solve problems outside of the care environment that can have a huge and costly impact on a patient’s well-being.”