Article Figures & Data
Tables
- Table 1.
Brainstorming Themes Regarding Social Determinants of Health and Primary Care, as Discussed at the 2017 Starfield Summit
Theme from Starfield Summit Participants' Discussion on SDHs Representative Statements from Group Discussion Reflecting Theme Addressing SDHs is a responsibility of primary care. “SDHs frame the health problems of our patients.” “In the United States, health care is used as a 'Trojan horse' for social services [because it is more acceptable].” “Data are needed to understand which SHDs are priorities to be addressed by primary care providers and how best to do so.” Innovations for addressing SDHs are outpacing the evidence. “Abundant emerging evidence supports the effect of SDHs on health outcomes/disparities, but less evidence exists for clinical interventions to mitigate SDHs.” “Intermediate outcome metrics for SDH interventions must be developed and validated. Long-term mortality and intermediate health biomarkers may be inappropriate metrics of SDH interventions.” “Public health and population health data should be better integrated at the point of care.” Qualitative data analysis of patient stories should be used to identify and address SDHs. “If the patient is at the center of health care, we need to hear about the patient experience.” “Patient stories can influence health care models and payment. Primary care should inform patients about the impact their stories can have.” “The act of sharing a story can be therapeutic in itself.” Relational leadership and community organizing are important, underutilized tools to address SDHs. “Coalitions start as 1 or 2 connections, and then they connect with others. Success depends on history and the process undertaken.” “Social movements and relational approaches do not play to the technical expertise as health professionals. We can embrace that as an opportunity for those with whom we partner.” “Academic medical faculty may feel less comfortable teaching about community organizing, but we can partner with community organizations to learn.” CHIPs create needed links across the medical-social neighborhood. “CHIPs create intentional strategies and tactical plans.” “In Oregon, everyone—hospitals, nonprofits, etc.—contributed to the CHIP. It was necessary to bring everyone together.” “Metrics are universal, so [CHIPs] can be universal too. They can cross ideological divides, like the cost of health care, and encompass SDHs and workforce issues.” Policy changes increasing payment and resources for addressing SDHs are necessary. “The fee-for-service payment model does not promote addressing SDHs.” “Attempts to address SDHs without proper resources in place could do more harm than good.” “Clinics need staff to connect patients with resources and to follow up to ensure coordination with these services.” CHIP, community health improvement plan; SDH, social determinant of health.
- Table 2.
Brainstorming Themes Regarding Vulnerable Populations, as Discussed at the 2017 Starfield Summit
Theme from Starfield Summit Participants' Discussion on Vulnerable Populations Representative Statements from Group Discussion Reflecting Theme Health care should recruit and train providers to understand the needs of their community. “Rural providers often grew up in rural communities; we should be recruiting trainees from these areas to return to these areas.” “Medical school admissions should systematically choose trainees most likely to serve the needs of populations.” “Most medical schools have limited curricula addressing vulnerable populations and social determinants of health.” Systemic injustices are institutional and structural, not just interpersonal. “Empowerment of the individual alone cannot be the only answer—the power of unjust structures often overwhelms individuals.” “We cannot talk about health disparities without talking about racism. There is a historic systemic inequity society is still trying to overcome.” “We need to consider oppressive societal forces, as opposed to focusing on vulnerable individuals or populations.” The elimination of injustice requires the solidarity of the advantaged. “Physician advocacy for health and rights of vulnerable populations is important.” “What happens to marginalized groups impacts all of society, and if injustices like racism and poverty are to be eradicated, those of us who are privileged need to do our part.” “There is a lack of knowledge and willingness for physicians to unpack what upholds our privilege, and this perpetuates the -isms.” Data collection of various social factors helps us better understand health inequity and intersectionality. “There must be recognition that certain vulnerabilities are currently invisible. Patients need to be asked about these.” “As certain vulnerable groups become more isolated, we must develop new methods for reaching them.” “When social data is collected, it needs to be correct, useful, and accurate. It's not 'Asian,' but Korean, Vietnamese, Taiwanese, etc.” “Qualitative data is important for understanding patients and their experiences better. Open ended questions such as 'Who are you?' may provide more useful information.” Collection of SDH data is insufficient alone; various factors contribute to interpreting data responsibly. “Analysis of a large single subpopulation eliminates the individual challenges faced by those who may fall into multiple vulnerable groups.” “There is missing or vague data that prevents informed decisions. For example, socioeconomic status is not often systematically queried, and immigration status might not be shared due to stigma and fear.” “Categories are not necessarily stagnant; for example, sexual orientation or socioeconomic status can change for individuals over time.” The system may need initial unequal investments to create equity for all. “Academic health centers should make disproportionately higher investments in vulnerable populations they care for.” “We need to redistribute privilege. Dismantling systemic and historic inequities is a health intervention, just like treating pneumonia.” “Often, making policies for one subgroup can cause others to feel left out or increasingly marginalized.” Policies should support a workforce working with vulnerable populations. “Medical education should develop robust training programs in areas of need and these sites should get incentives to do so.” “The system should develop financial and resource support for smaller clinics and hospitals, which often serve vulnerable patients.” “Often, it may be beneficial to bring health care to individuals who are vulnerable rather than having them overcome barriers to present at a health care institution.” SDH, social determinant of health.
- Table 3.
Brainstorming Themes Regarding Economics and Policy, as Discussed at the 2017 Starfield Summit
Themes of Starfield Summit Participants' Discussion on Economics and Policy Representative Statements from Group Discussion Reflecting Theme Health equity research should move from studying disparities and toward implementing solutions. “Individuals and systems are frustrated about collecting health disparity and health equity data without established evidence-based mechanisms with which to act on data.” “The field of implementation science provides a conceptual framework to take existing knowledge about health disparities and demonstrate interventions that promote health equity.” “Health equity policies should be driven by attainable patient-oriented outcomes.” Health equity interventions should balance both individual and community-level risk factors. “Individuals living in the same zip code can have vastly different social determinants of health.” “Care decisions should be informed by both immediately ascertainable individual medical data and historical community-level public health data.” “Real-time public health data streams could make social determinants data more relevant and actionable.” Solutions to address health equity should use a team-based approach. “Individuals from the community, as health workers, have the potential to understand community needs and effectively connect patients with resources.” “We need to think about expanding the workforce to address SDHs… . Data from HealthLeads shows that one-time passive referrals are much less successful than ongoing coaching.” “Electronic health records limit data-sharing between systems, but understanding how individuals use various sectors [eg, clinic vs. hospital] is crucial to coordinate care.” Health care payments should be risk-adjusted for sociologic data. “Enhanced payment models need to incorporate a marker for social complexity and its impact on health outcomes.” “Centers for Medicaid and Medicare and other private groups are exploring how to operationalize socioeconomic status in healthcare payments.” “Other countries' [eg, New Zealand, United Kingdom] experiences with social deprivation index-linked payment adjustments could inform US interventions.” Redistributing payments from health care to the social service sector supports health equity work. “Primary care clinics may not be the ideal location to address social determinants of health, despite the fact that primary care intimately interacts with the social issues that affect peoples' lives.” “The social services and primary care health system must work in collaboration to gather health equity data and subsequently act upon social determinants.” “Enhanced payment models for social complexity should pay for appropriate health care and appropriate community-based services.” Alternative payments for health equity work in primary care should be pursued. “Alternative payment models will increasingly hold health care delivery organizations accountable for social factors outside of the clinical setting, which may produce dangerous disincentives to care for socially disadvantaged patients.” “Innovative financing mechanisms, such as social impact bonds and benefit corporations, may provide avenues for private-sector investment in health equity.” “Future ideas should focus on creating public-private partnerships and incentivize these relationships for private companies.” Primary care should influence political structures that heavily impact health equity. “Globally, there appears to be a threat from government structures to move health systems away from people-centered services.” “Our system needs leaders who embody the ethics of equity and this may involve addressing political realities.” “We need to move beyond a profit-driven system to one that is rooted in morality.” SDH, social determinant of health.
Theme Implications for Action Education Incorporate advocacy, community organizing, and relational leadership skills into medical education to enable future health professionals to partner with communities to create social change. Change admission policies for health professional institutions to prioritize recruiting individuals from underrepresented populations and communities of need. Improve didactic exposure to vulnerable groups in health professional education and provide in-person experiences with these populations. Clinical practice Use validated screening tools to identify SDHs and social needs. Create data-enabled teams and workflows to identify and address SDHs in the context of the clinical setting. Develop roles in team-based primary care that include creating meaningful partnerships with community members and organizations (eg, community health workers, community organizers). Examine each clinical encounter from the perspective of systemic injustice or structural violence. Research Partner with clinicians to develop and validate SDH screening tools; partner with educators to develop and measure effectiveness of health equity curricular elements. Focus on implementation science research that highlights characteristics of feasible, replicable interventions that identify and address SDHs at the clinical level. Develop and validate new metrics that gauge the impact of health equity interventions, with a focus on implementing patient-centered outcomes (eg, self-efficacy, social connectedness, quality of life). Engage in research focused on integration of individual-level SDH data with population and public health outcomes. Policy and advocacy Invest in community partnerships and health information technology to develop workflows that improve data sharing between primary care, public health, and local social services. Partner with patients and use their stories to advocate for policy change that positively affects SDHs and their effects on health care. Ensure that all institutional and policy decisions include an equity lens. Advocate for alternative payment models that enable primary care delivery to integrate social services and community partnerships, such as individual- and community-level risk adjustments for SDHs. SDH, social determinant of health.
