The Journal of the Arkansas Medical Society Issue 3 Vol 115 | Page 5

COMMENTARY Appathurai Balamurugan, MD, DrPH, MPH When the Rubber Does Not Meet the Road W e are familiar with the phrase, “When the Rub- ber meets the Road,” and often use it to refer to when words are or are not translated. In the context of clinical practice, we encounter some of our patients who may know what needs to be done or hear from us what needs to be done to improve their health – be it medication adherence or lifestyle modification for chronic disease man- agement – but are regularly nonadherent. While sometimes, we may stop and reason out why, many times in our busy practice we don’t have time to stop and think or ask why. When the rubber does not meet the road, do we regularly stop to think or ask why? One of the commonly cited reasons for this has been the challenges posed by non- medical social needs or social determinants of health. The conditions in which people are born, grow, live, work, or age that influence individual choices and significantly impact health are defined as the social determi- nants of health (SDOH). These conditions are, in large part, responsible for the health inequities that pervade our society at pres- ent times. A renowned physician and epide- miologist, Sir Michael Marmot, states, “Why treat people and send them back to the conditions that made them sick in the first place?” Assessing and addressing the conditions that made them sick in the first place would be a good first step to achiev- ing health equity. The Department of Health and Human Services Officer of Disease Prevention and Health Promotion describes five key areas of SDOH, as illustrated in the schema here. They are as follows: • Economic stability (employment, food insecurity, housing instability, poverty) • Education (early childhood education and devel- opment, enrollment in higher education, high school graduation, language and literacy) • Social and community context (civic participation, discrimination, incarceration, social cohesion) • Health and health care (access to health care, ac- cess to primary care, health literacy) • Neighborhood and built environment (access to foods that support healthy eating patterns, crime and violence, environmental conditions, quality of housing). These key areas impact our patients, prevent- ing them from making health a priority. These five key areas impact health in various ways; for exam- ple, housing instability could include homelessness, difficulty paying rent, or poor housing conditions due to bug infestation or mold, and could lead to respi- ratory and cardiovascular diseases, death from ex- treme temperatures, or risk of at-home injury. Lack of child care could be a barrier for educational or employment opportunities for patients. Exposure to interpersonal or community violence may impact the physical and emotional health of our patients. The American Academy of Family Physi- cians and other national organizations have de- veloped some screening tools (https://www.aafp. org/patient-care/social-determinants-of-health/ everyone-project/tools.html#patients) for SDOH that can help identify specific needs or challenges faced by our patients. These screening tools can be administered by receptionists or medical as- sistants, or integrated as part of intake form in patient’s electronic health records. Nurses, phy- sician assistants, or physicians can review the completed SDOH screenings to determine patient needs and create an action plan during the visit. Engaging care managers, social work- ers, or community health workers to deter- mine available resources in the community, facilitate referrals, and ensure follow-up between patient visits would go a long way toward improvement. Each patient’s need may be different, as there is no one-size- fits-all in addressing SDOH. Some social services available at the practice level to help address social needs of the patients include a free, online social services search engine called Aunt Bertha (www.auntb er- tha.com), 211 Helpline Center, and State Health Departments (https://www.healthy. arkansas.gov/resources). The SDOH screening tools and patient action plan provide a starting point to assessing and ad- dressing SDOH in a busy practice. With the move- ment toward value-based payment models, phy- sicians are held accountable for health outcomes rather than processes. Assessing and addressing SDOH would assist with behaviors and social fac- tors that impact health outcomes. The views expressed in this commentary are that of the author and are not necessarily those of the Arkansas Department of Health. NUMBER 3 SEPTEMBER 2018 • 53