Addressing Social Determinants of Health: Finally, Tools for Primary Care

Interviewer: Laurie Scudder, DNP, NP; Interviewee: Danielle Jones, MPH


October 10, 2018

Editorial Collaboration

Medscape &

It Takes a Village

Medscape: You have noted that a team-based approach is the ideal way to address SDoH. Which team members do you think are essential?

Jones: We view the entire practice team—the receptionist, office administrator, nurse, medical assistant, community health worker—as essential. But what we hear the most from practices that are successful in integrating screening and addressing SDoH is that they are working with people like social workers, community health workers, and behavioral health specialists, who may have more familiarity with the social services that are available in their local community. Those specialists may be better prepared to do the handoff between patients and resources out in the community.

Medscape: I presume that the social worker may not necessarily be an employee within the practice but rather a community-based resource that the practice uses to assist them.

Jones: Correct. While these professionals could actually be embedded in the practice, we know that this is not always the case. We really emphasize physicians going out and establishing peer relationships with other disciplines. That then provides an opportunity for the physician to refer to a colleague who is a social worker or behavioral health specialist, who may be more familiar with community resources and can assist with identifying the best match for an individual patient's needs.

We want to emphasize that physicians have a very powerful voice in their communities. And we want to provide the resources to teach physicians how to leverage that voice and influence.

Medscape: Should practices partner with each other to permit a community-wide response to SDoH that likely affects patients throughout the community, not just in one practice?

Jones: Absolutely. One of the things we address is the impact of local collaborations. These might involve one or more primary care practices, a local health department, or a community service organization that forms a coalition to create a local safety net for some of that community's most vulnerable populations. We definitely want to encourage our members to identify any of those existing coalitions and collaborations. If they do not already exist, a family physician can champion the development and implementation of those kinds of networks. If a practice or coalition of organizations is offering a service in the community that is not listed in the Neighborhood Navigator, they can actually go in and have that information uploaded to the system.

Medscape: Addressing SDoH on a community-wide basis will also require a governmental response; The EveryONE project does address that issue. Can you speak to tools that are available to assist busy physicians in their role as advocates—without being overwhelmed by the time demands?

Jones: One of the benefits of having a local interdisciplinary collaboration is that it allows our physician members to be able to work with other people in the community to start talking holistically about their collective challenges. That hopefully permits identifying some of the root causes of these issues. Is this a system issue? A policy issue? An infrastructure issue?

Once that has been identified, the coalition can strategically develop a way to address it. We want to emphasize that physicians have a very powerful voice in their communities. And we want to provide the resources to teach physicians how to leverage that voice and influence to be able to speak to legislators, system administrators, or community leadership. Our members represent the voice of the patient, so it is critical that they have the resources to be able to influence the development and implementation of the policies and tools with downstream outcomes that affect health.

Resources From AAFP

AAFP's Neighborhood Navigator Neighborhood Navigator

AAFP News: AAFP Takes Leadership Role With Launch of Center for Diversity, Health Equity

AAFP News: The EveryONE Project Debuts at 2017 Family Medicine Experience

AAFP: The EveryONE Project

The EveryONE Project Toolkit: Guide to Social Needs Screening Tool and Resources

The EveryONE Project Toolkit: A Team-Based Approach for Advancing Health Equity

AAFP member survey: SDoH: Family Physicians' Role

AAFP Advancing Health Equity: Principles to Address the Social Determinants of Health in Alternative Payment Models

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