How much should physicians be responsible for addressing social risks to their patients?
If health care providers are to consider all risk factors that will inevitably impact health, one might argue that it is equally important to know whether patients have stable housing and employment and can afford basic necessities such as food.
When a newborn arrives at my pediatric practice for the first time, usually just a couple of days old, that person’s medical journey is just beginning. During the visit, I fully review the mother’s pregnancy history, the family’s medical history, any challenges related to birth, and early signs or symptoms that the infant is flourishing or having trouble. Hopefully all goes well, and I can establish a follow-up appointment to discuss when the their first vaccinations for the child should be scheduled.
But is that where my responsibility ends? If we are to consider all risk factors that will inevitably impact a child’s health and trajectory, one might argue that it is equally important to know whether the family has stable housing and employment, can afford basic necessities such as food, and whether the mother may be at risk for depression, or worse yet, unsafe in her own home.
When I asked about life at home for one family, the mother informed me that she was living on a friend’s couch, had not finished high school, and was severely anxious about the responsibilities of caring for her newborn. I felt slightly hopeless in that moment, wondering whether raising issues that I could not adequately address was more harmful than helpful.
These issues related to social and environmental risks that families experience, termed the “social determinants of health,” are a hot topic in medicine today. Of all the factors that contribute to an individual’s health, nearly 80% involve these social determinants, while only 20% relate to health care services. National entities such as the American Academy of Pediatrics and the Centers for Medicare & Medicaid Services have identified how critical social determinants are to health, and even state governments are increasingly taking notice. The Commonwealth of Pennsylvania, for example, now requires health systems working with Medicaid-enrolled patients to more regularly screen for social determinants of health.
That said, as policymakers and the health care industry increasingly recognize the impact of social risk on patients’ health, we should pause and ask whether, despite good intentions, this is the role of health care providers.
Many of my colleagues in health care are concerned about where the boundaries of our responsibilities lie; we are working hard already just trying to attend to our patients’ medical needs. Others may weigh whether asking questions about social determinants, as I did, and uncovering issues we cannot easily resolve is ethical. Many health care executives are debating the boundaries of a health care organization’s investment in “non-medical” services. Are health systems meant to pay for housing, food pantries, or other services for which insurance companies don’t reimburse?
Fortunately for me and my peers, new solutions and services make asking families about their health-related social needs less daunting. More sophisticated technology allows clinicians to better organize and identify risk among large groups of patients or generate resource maps of potentially helpful community services. At Children’s Hospital of Philadelphia (CHOP), for example, we are partnering with software developer Aunt Bertha to create such a map for the Philadelphia area so our patient families and providers have at their fingertips a curated list of food pantries, counseling and housing services, and other resources.
At the point of care, many health systems are investing in social workers and community navigators who visit patients in their homes to ensure they are able to adhere to medical plans physicians create, which has proven to greatly improve medical outcomes. Still others, CHOP included, are increasingly hiring from low-income communities, establishing food pantries, or investing in repairing housing for children with asthma or other complex medical needs.
This is truly an exciting time in health care. While the resources to identify and address social determinants of health may be scarce, new solutions are emerging through partnerships with community agencies.
What I have learned, though, is that even when we don’t have a direct solution, the engagement and interest in our families goes a long way. Take the family I mentioned above. After hearing the mother’s story, I must admit that I wasn’t able to get her affordable housing — the waiting lists in Philadelphia are too long — or expedite her appointment for behavioral health services. Regardless, I sensed some weight lifted off her shoulders by my simply acknowledging her challenges, helping her establish smaller goals such as returning to school, and assuring her — with the help of a terrific social worker — that she had access to food-assistance programs.
Two weeks later, she returned for a follow-up visit. She was still sleeping on a friend’s couch, she told me, but she was feeling much better. Just knowing that she had someone who cared about what she was going through was enough to feel less isolated. That alone is an important intervention none of my colleagues should ever doubt.
David Rubin, M.D., M.S.C.E., is the director of Population Health Innovation and PolicyLab at Children’s Hospital of Philadelphia, and a member of the Inquirer’s Health Advisory Panel.