CHICAGO—To drive home the importance of how social determinants can make or break a person’s health, Jillian Rose, LCSW, MPH, the director of community, engagement, diversity and research at the Hospital for Special Surgery in New York City, told a story about a gardener planting flowers at the 2018 ACR/ARHP Annual Meeting.
Explore this issueJanuary 2019
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In the story, “The Gardener’s Tale,” by Camara Phyllis Jones, MD, MPH, PhD, the gardener has just moved into a new home and uses the flower pots that still have soil in them, rocky and ill-nourished, for pink flowers. At the same time, she plants red flowers in pots with new soil. The red flowers flourish, and the gardener tells herself: “I was right to prefer red over pink.”
In the healthcare world, Ms. Rose said, the old soil equates to crucial, but often overlooked, factors that can steer a person to health or illness: food, lack of transportation, poverty. Too often, she said, healthcare providers breeze past these factors in their interactions with patients, usually without even realizing their own biases.
“We’re often the gardeners in our patients’ lives,” Ms. Rose said, “unconscious of how the care we’re providing is laden with unconscious biases, shaped by our experiences, and how they can influence outcomes by triggering our patients’ thoughts, feelings and perceptions, which causes them to [either] build trusting relationships with us and grow and get well, or to just wither away.”
What to Look For
Social and economic factors account for 40% of health determinants, according to a 2017 publication by the Center for Health Care Strategies, a figure also cited by the Los Angeles County Public Health Department.1 Biases can be rooted in race, age or gender, Ms. Rose said, and they have real consequences.
“Not assessing social history or challenges can lead to inappropriate care, such as a patient not being able to afford the medication we prescribe,” she said. “That treatment has fallen apart as soon as that patient has left the room.”
Providers must look for “clinical red flags,” she said, such as child or elderly abuse or human trafficking, using a selective inquiry based on clinical considerations. Don’t think of it as an extra layer of the clinical visit, but just a normal part of the clinical evaluation, intended simply to treat appropriately.
Tools for helping understand the patient’s context for health include PRAPARE, the Protocol for Responding to and Assessing Patient Assets, Risks and Experiences, and the Center for Medicare and Medicaid Innovation’s Health-Related Social Needs Screening Tool.