Minority Health Month: What Social Determinants Tell Us About Health Equity

Chelsea King Arthur, Vice President, Population & Digital Health Solutions, and Maria Reese, Senior Director, Health Equity and Community Service Programs explore the importance of social determinants of health during Minority Health Month.

April is Minority Health Month, and this year’s focus is on providing racial and ethnic minority and AI/AN communities with “culturally and linguistically competent healthcare services, information, and resources.” We know that when patients are provided information that is culturally and linguistically appropriate, they are more likely to engage with that content and take a more active role in their healthcare, driving better individual outcomes, as well as improved population outcomes. As we reflect on the theme of “better health through better understanding,” it’s important to examine how social determinants of health (SDOH) play a role in better understanding health equity.

We’re now fully three years since the COVID-19 pandemic cracked open the issue of health disparities. SDOH and health equity have become common words across the healthcare industry as public health professionals and practitioners give a head nod and say, “It’s about time we can speak the same language, now let’s work together to make an impact.” But these are not new terms. Public health and forward-thinking healthcare systems have been working to address health inequities and provide whole-person care for decades. 

Where once it may have felt like being on an island with just a few ambassadors, now most healthcare systems, non profits, and even healthcare plans are paying attention. New positions, funding, and research have been developed to focus on the importance of SDOH and how to solve alarming health inequities. 

The COVID-19 pandemic shed light on health disparities and inequities and forced the entire healthcare delivery system to take notice. As vulnerable populations across the United States and low income neighborhoods were hit significantly by the disease, the mortality and morbidity numbers could not be ignored any longer.  

The notion of health geography (the application of geographical information to study health) and removing barriers for improved health were finally being recognized. The idea that the ZIP code of a person is more important than their genetic makeup has changed the way we work with the community. This is a prime example of how racism and injustice are built into our society with such complexity that it is difficult to untangle this deep-rooted health inequity. 

Screening for social determinants  

We may be talking about this issue now during Minority Health Month, but we recognize that health equity challenges are pervasive all year round. The Robert Wood Johnson Foundation defines health equity as when “everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” 

One way we can begin to achieve health equity is by screening for SDOH and connecting people to necessary resources so there is a level playing field for ALL. If we can remove barriers for quality access care and begin promoting health for everyone, we can improve health outcomes. 

We are now learning that only 20% of health outcomes are influenced by clinical care. The other 80% of health outcomes are influenced by physical environment, health behaviors, and SDOH. SDOH are defined as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” 

When we screen for SDOH conditions such as access to food, safe housing, reliable transportation, interpersonal violence, and social support, we are going upstream to get closer to the root of the problem so we can care for the whole person longer term. For example, a patient who screens positive for housing instability could be experiencing poor health due to environmental stressors such as air pollution, mold, lead poisoning, crowded space, or mental stressors from having to move often, uncertainty of rent, or homelessness. The combination of these stressors can lead to a multitude of physical and mental health challenges including asthma, high blood pressure, infectious disease, anxiety, and depression.

Identifying the problem and connecting the patient with immediate resources and sustainable support gives healthcare organizations a better chance of addressing the underlying social care concern, which results in improved health outcomes. However, according to the results of a survey published in 2022 in The Annals of Family Medicine, while most participants believe that health systems should address social risks of patients, a minority of the survey participants who reported a social risk actually “wanted assistance and reported more discomfort being screened for risk factors than those without risks.” To address this hesitancy, collection of social risks and needs must be done in a way that is comfortable to the patient and one in which they understand that their vulnerability is not a liability, but rather an opportunity to further engage with their care providers. The study concludes that health systems should determine ways to successfully assist patients when they desire help and “offer resources to address these risks outside of the healthcare sector.”

Policy changes and guidelines move the SDOH needle

Despite patients and health system leaders understanding that healthcare providers play a role in addressing social risks, a recent survey conducted by the Health Equity Alliance showed that many healthcare systems that prioritized health equity during the COVID-19 pandemic have since reported a drop in priority. This is largely due to other focus areas such as teammate retention and well being, consumer strategy, data and analytics, and financial health leaping to the top of the priority list. However, this is not the time to take our foot off the pedal for health equity.  It is the precise time we need healthcare systems to step up and use their influence, leadership, resources, and advocacy to be the light for our most underserved populations.  

With new guidelines coming down from CMS to screen patients for social care needs and connect them to resources, it is imperative healthcare organizations have the technology and process to standardize this across their systems so they can gain reimbursement. More than 35 states have one or more mandates or requirements for MMCOs concerning SDOH, including mandates around screening for social needs, providing referrals to social services, and tracking the outcomes of social service referrals. Additionally, there is an appropriations bill for approximately $324 million that aims to improve maternal health and reduce the nation’s alarmingly high maternal mortality rate. This will fund stronger data systems to improve surveillance and help expand programs that are proven to be successful at reducing maternal mortality.  

Committing to health equity: 10 tips for success

At Get Well, we’re serious about addressing health equity — and not just during Minority Health Month — and we invite healthcare systems to join us or even partner with us in this important work. 

Get Well is committed to being intentional and serving as a role model for integrating health equity across all of our solutions and programs. 

  1. Health Equity (HE) Council: If you’re going to talk the talk, you have to walk the walk. Develop a diverse HE council of internal teammates and leaders across the organization to build a strategy with measurable outputs. It must be endorsed by the CEO and board. 
  2. Utilize navigators: Hire empathetic navigators who represent the communities you serve to deliver personalized care through texting and phone calls. Bi-lingual navigators with a background in public health, social work, healthcare, customer service, or a related field are invaluable assets.  
  3. Language: All written education and content should adhere to health literacy principles and feature plain language at a 7th grade or lower level. 
  4. SDOH screening: Screen for SDOH, connect patients with community resources (race and ethnicity based), and follow up for closed loop referrals. Partner with organizations that specialize in resource coordination and referrals, such as Find Help.
  5. Risk stratification: Social care and behavioral health risk stratification helps provide patients a clear pathway for low-, middle-, and high-risk needs. This also allows for appropriate escalations.
  6. Education and advocacy: Health education and content for programs should be culturally appropriate. Include information and content that empowers, educates, and advocates for diverse and vulnerable populations. 
  7. Patient feedback: Ensure that diverse patient input and feedback is provided on a regular cadence to inform the service delivery and quality improvement process.
  8. Training for teammates: Fund training for all teammates and leaders to deepen their understanding of health equity and literacy (i.e., cultural competency, unconscious bias, trauma informed language, SDOH, diversity and equality, Mental Health First Aid). 
  9. Invest in health equity measurement: Measuring health equity is imperative for understanding if everyone has the opportunity to benefit from initiatives and using the data to inform changes in the service delivery. 
  10. Digital solutions: Design and utilize AI technology to minimize the impact of healthcare inequities among communities that have been underserved. Implement evidence-based interventions such as texting to meet the patients where they are. 

The bottom line

As we kick off Minority Health month, it’s important to remember that efforts to address health equity aren’t confined to one month. We may be talking about it more right now, but it’s something we should be working to solve for all year long.

Screening for SDOH needs can help healthcare organizations better understand all of the aspects of a patient’s needs, including those that extend beyond the clinical ones found in the medical record. Digital technology holds the potential to leverage this data and drive meaningful strides in providing equitable and personalized care for all.

Learn about Get Well’s work to improve health equity and address SDOH. Schedule a demo and learn how you can partner with us today to change tomorrow for those most in need.