June 28th, 2019
Health care researchers and providers are increasingly aware of the importance of addressing social and environmental factors outside of the clinic that determine health. Many health care institutions have started programs to screen patients for social issues that affect health such as food insecurity, housing instability, or intimate partner violence, and then refer patients to community programs that provide resources to solve these problems.
However, there are many other ways in which health care institutions can address social determinants of health beyond screening and referral. At an event organized by MLPB, a medical-legal partnership organization that addresses health-related social needs in New England, health care leaders shared how they are improving access to both health and social services at their institutions. Here are a few of our takeaways:
When patients walk through the door of a clinic or hospital, their first impression can affect their experience going forward. For Whitman-Walker Health, a federally qualified health center in Washington, DC, specializing in LGBT care, creating a comfortable environment was crucial for building relationships with patients, said Erin Loubier, Senior Director for Health and Legal Integration at Whitman-Walker. Whitman-Walker remodeled their space, turning it from a dark and foreboding waiting area to one full of light. They also made sure all restrooms were gender-neutral and that staff name tags included their pronouns, so that patients would feel comfortable no matter their gender identity.
At Stanford Children’s Health, which serves families of various immigration statuses, putting up signs reading “All are welcome” in different languages was a simple step to build trust with families, said Dr. Baraka Floyd, Clinical Assistant Professor at the Stanford School of Medicine.
One of the most important ways that health care institutions can serve people in their community is by finding out the most pressing need for people in their community and providing this need. For example, Whitman-Walker Health started offering legal services to change identity documents for people undergoing a gender transition, which brought in many new patients who also had health needs to address. By identifying their patients’ most important need, Whitman-Walker Health engaged patients who otherwise would not have come to the clinic, said Loubier.
Asking patients questions about their economic and housing needs is a new process at most health care institutions, and can bring up issues that are difficult to talk about. That’s why it’s important to explain the reasons behind the screening before asking sensitive questions, said Floyd. Clinicians should be screening not just for risk factors but also protective factors — what economic, educational, and social assets do patients have that can provide resources? Learning about patients’ strengths can help clinicians prioritize their social needs and create a plan that utilizes these strengths.
Patients are often asked to do a lot by health care systems, not all of which fit in with their daily lives. For example, appointments may require taking time off work, securing childcare and transportation, which is not always feasible for patients. Then, patients may be blamed for being “non-compliant,” which can strain relationships between clinicians and patients.
Dr. Dannie Ritchie, Founder of Community Health Innovations of Rhode Island, asserted that we need a reframing of the issue of “patient compliance.” We have to recognize that patients have many competing priorities, so health care organizations have to work toward helping patients’ basic needs. Again, creating a welcoming environment is key. “Why would someone make an appointment to go to a hostile place?” said Ritchie.
In Floyd’s experience, teaching medical students to go beyond the one-dimensional model of “adherent vs non-adherent” is critical. She tries to get physicians to ask, “What is the barrier that’s making it difficult for this patient to adhere to a certain treatment?” Then, they can address the underlying issues, not just put a band-aid on them.