It has long been understood that social and economic factors can impact health outcomes, said David E. Vollman, MD, MBA, at St. Louis University School of Medicine. The umbrella term social determinants of health (SDOH) is used to describe these factors, which “can sometimes be even more important than the direct clinical care that we give patients.”
An increased focus on SDOH. In recent years, there has been a heightened focus on SDOH and the corollary issue of health equity, said Dr. Vollman. There are several reasons for this, including well-publicized discrepancies in health outcomes during the COVID pandemic, as well as changes in reimbursement models as some payers move to risk-based contracts, he said.
What role for the ophthalmology practice? Many practices are already adept at handling one of the primary SDOH problems—the uninsured or underinsured patient’s inability to pay. And once practices are more familiar with the resources that are available for other SDOH issues, they can become more comfortable in addressing some of those challenges, too, Dr. Vollman said.
Ophthalmology and SDOH
SDOH problems “can be interrelated, feeding into each other,” said Dr. Vollman. They can include financial issues, lack of transportation, food insecurity, education, housing insecurity, work issues, and lack of social support.
Financial insecurity. There have always been patients who need exams, medications, or surgery but can’t afford to pay. How can your practice help such patients without imperiling its bottom line? To help offset some of the costs, practices will need to know how they can get patients plugged into pharmaceutical or drug manufacturer’s assistance programs, said Dr. Vollman. You also should explore what help is available from state agencies, foundations, and public charities, said Joy Woodke, COE, OCS, OCSR, Academy director of Coding and Reimbursement. “The Lion’s Club, for example, provides help for cataract surgery and eyeglasses.” (See “Use ECA’s Resource Lists.”)
Unreliable transportation. See if any local organizations can help patients get to your office. If no help is available, and transportation problems mean that patients can’t reliably make it to their appointments, you might need to change their treatment plan, said Dr. Vollman. “For example, with neovascular age-related macular degeneration, the doctor may consider using a longer lasting medication. But the challenge there is that those medications are more costly, and this is where these social determinants sometimes cycle into one another.”
Food insecurity. A lack of food security is associated with a higher probability of chronic disease.1 If, for example, diabetics are forced to skip meals, they are more likely to have hypoglycemic episodes, which can contribute to both systemic and ocular disease. One way to address this is to connect the patient with a local food bank. Dr. Vollman described how SSM Health De Paul Hospital in St. Louis has taken this a step further. It partnered with Operation Food Search (www.operationfoodsearch.org), which is a regional charity, and the St. Louis Food Bank and created a food pantry in the hospital itself. Physicians can give a prescription for food to a patient, who can then stop by the pantry to pick up about a week’s worth of groceries before leaving the hospital. “When they get home, the local food bank will reach out to them and try to establish a more long-term solution,” he said.
In addition to connecting patients with local charitable resources, which you may be able to find using https://findhelp.org, see if your patients are taking advantage of federal programs, including the following:
Education level. In talking to patients, you need to make sure you present information at their level of understanding, said Heather Dunn, COA, OCS, CSR, Academy manager of Coding and Reimbursement. “For example, young parents with high-risk infants sometimes have trouble comprehending the long-term consequences if their child’s care is neglected.”
Housing insecurity. “Suppose you need to do surgery on a patient who doesn’t have stable housing,” said Dr. Vollman. “That housing insecurity could make the outcome of the surgery less than ideal.” Ms. Woodke agreed, adding that the anxiety of worrying about where to recover after surgery can overwhelm the patient and impact healing.
Work. Workplace-related illnesses and injuries aren’t the only way that a patient’s jobs can impact their health. “People might have a hard time getting off work for appointments,” said Ms. Dunn. “They also may not know their shift schedule until the week before, which limits future planning and results in many rescheduled appointments.”
Lack of social or family support. Without a supportive network of family and friends, obstacles to obtaining care may seem insurmountable, said Ms. Dunn, who gave the example of an older patient who has an extensive list of prescription medications. “Without help, she may have difficulty remembering when to take them, when to taper them, or even why she takes them at all,” said Ms. Dunn. Older patients may also need help in understanding technology, vocabulary, and consents—“but they hate to admit that they need help because they fear losing what independence they have.”
Other SDOH. Other potential SDOH problems include safety in the home, unemployment and job security, early childhood development, foster care, and social inclusion.
Tips for Addressing SDOH
Screen for SDOH. A patient may be struggling with an acute SDOH issue but may not be open about sharing that with you, said Dr. Vollman. “This is especially true if it is early in your relationship with the patient, so you need to be proactive.” To overcome a patient’s reticence, you will need to “probe empathetically,” he said. CMS and organizations that represent primary care clinicians have developed screening tools for SDOH, including the following:
“Even if you don’t hand out these surveys, physicians and staff may find the questions helpful if they want to approach patients about potential social or financial problems,” said Ms. Woodke.
Appoint an SDOH point person. “Assign a staff member to be the patient ambassador,” said Ms. Woodke. This person would compile the many community resources for low-income patients—including transportation and temporary housing—as an easily accessible resource, she said. “They would connect patients with social workers to assist with the application process for state benefits. Additionally, they would be the expert in the patient copayment or assistance programs.”
Align with larger organizations. Private practices have limited capacity to address SDOH on their own, but they can align themselves with larger organizations in their area, said Dr. Vollman. Organizations such as the United Way and YMCA may be able to help patients address negative SDOH, he said. “Establish a point of contact at these entities, so you’ll have someone who you can refer patients to.”
Stay in touch with the patient’s primary care doctor. Maintain a working relationship with the referring primary care doctor, as he or she may have some insight into the patient’s SDOH, said Dr. Vollman. He added that “the primary care practice also may have more experience in plugging patients into local resources.”
Check with payers. If patients have at least some insurance, their insurance company may have a program that assists them if they are underinsured, said Dr. Vollman.
Get involved in advocacy to tackle SDOH at a societal level. “If you want to make larger change, you should get involved in advocacy at the state and national level,” said Dr. Vollman. An easy way to get started is to join the Academy in its advocacy efforts. To find out how you can get involved, go to aao.org/volunteering, select “Advocate,” and review your options.
Your Next Steps
Even the large health care systems are struggling with how to address negative SDOH effectively, said Dr. Vollman. “Any private practice that is starting to address SDOH shouldn’t feel discouraged if they find it a challenge. But if practices start to take little steps—even if it is just physicians educating themselves and their staff about the issues—that would lay the groundwork for more substantive change.”
For an overview of how disparities in patient care play out in glaucoma diagnosis and treatment, read “Tackling Health Care Disparities” (EyeNet, June 2021).
1 Gregory CA, Coleman-Jensen A, for the USDA Economic Research Service. Food Insecurity, Chronic Disease, and Health Among Working-Age Adults, Economic Research Report 2017(235). www.ers.usda.gov/publications/pub-details/?pubid=84466. Accessed June 16, 2022.
Ms. Dunn is Academy manager of Coding and Reimbursement. Relevant financial disclosures: The Academy: E.
Dr. Vollman is Regional Vice President of Medical Affairs for Specialty Care at SSM Health and Adjunct Associate Professor of Ophthalmology at St. Louis University School of Medicine. Relevant financial disclosures: None.
Ms. Woodke is Academy director of Coding and Reimbursement. Relevant financial disclosures: The Academy: E.
See the disclosure key at www.aao.org/eyenet/disclosures.