Lydia Mills, MSW, LCSW, LICSW, is a senior manager of Supportive Care Programs, Clinical Services at McKesson and was previously a practicing social worker within The US Oncology Network. In this Q&A, Lydia shares how she defines social drivers of health (SDOH), the SDOH factors we should be paying more attention to and why it’s important we capture SDOH data in EHRs.
How do you define social determinants of health from the viewpoint of a social worker?
In the field of social work, we have started to shift to the term “social drivers of health”. This better communicates that there is opportunity to make change, whereas the word “determinants” implies that a person’s social circumstances will remain the same.
We consider social drivers to be the environment that a person is in – and it’s not just where they are right now but also where they’ve come from. In social work, we’re trained from a “person in environment” theory. This means that we are examining a person within the context of their environmental circumstances. Environment includes things such as one’s living situation, level of education, age, race, sexual orientation, where a person grew up and how they were raised, where they are living now, among other factors. We want to consider anything that impacts a person. So often in healthcare the aim is to treat the diagnosis, but we try to look at the whole person.
How do SDOH play a role in the responsibilities of a social worker?
When we meet with a patient, we do a full biopsychosocial assessment. This means that we’re asking questions about the patient and what is going on in the multiple domains of their life. As mentioned before, the primary diagnoses they are seeking treatment for is just a small piece of the puzzle.
To share an example: a social worker may get a referral because a patient is having trouble getting to their appointment. A social worker will sit down with the patient and ask questions to learn more about the patient and their situation, such as, “I understand you’re having trouble with transportation. What else is happening right now that is causing trouble with transportation? Do you have a car? Do you know someone who might be able to drive you to appointments? Can you tell me a bit about your financial situation?” And we build on those questions to get a full picture of the person and their environment. We then have a responsibility to share the relevant information with the healthcare team so that everyone has a better understanding of the situation.
What SDOH factors do you think have the greatest impact on outcomes?
What comes to mind when considering this question is Maslow’s hierarchy of needs. In this theory, there is a five-tier pyramid of human needs. At the base of the pyramid is physiological needs, or basic needs such as food and shelter. Though basic needs may sound simple, they are really impactful to an individual. This encompasses questions such as, “Does this person have a place to live? Do they have enough food? Do they have money for food?” Whether basic needs are met can have tremendous influence on healthcare outcomes.
Are there SDOH factors that you think are often overlooked or that we should be paying more attention to?
Awareness of SDOH and their impact is coming to the forefront of discussions in healthcare, and I think this recognition will help us push health equity forward as a society.
I think as we consider the SDOH factors that influence a patient’s care and outcomes, we’ll start to see more discussion of mental health and emotional needs. Mental health history is really important, and recognition of this history may influence a patient’s treatment plan and follow-up care. Additional factors to consider are support systems (who or what gives a patient support and strength) and spiritual orientation (what guides a patient and how they may derive meaning or value in life).
Additionally, financial status has a huge impact on care and outcomes and is often not discussed, as it can be an uncomfortable topic for many. A healthcare provider may share the cost of care but not delve into how a patient is going to pay for said care. But the ability to afford healthcare can have a major impact on how a patient experiences the healthcare system.
How do social workers interact with physicians in a healthcare system? What is that relationship like?
Speaking from my experience working in The US Oncology Network, there is a great relationship between social workers and physicians. You do have to build that rapport, but in my career, my colleagues and I have been very comfortable knocking on a physician’s door and sharing relevant information we have learned about a patient.
An example of a meaningful interaction between a social worker and physician is when a social worker is asked to help facilitate a difficult conversation between the physician and a patient, such as change in prognosis. In our role, we have the skillset to manage the range of emotions that a patient may experience and can help the physician navigate this discussion.
Why do you think it’s important that we capture SDOH data in EHRs?
From a social worker’s perspective, I think it helps to tell the story of a patient. Their diagnosis is just a small piece of the puzzle and then all of the other questions we’ve discussed help round out our understanding, which can help the care team better understand the patient and their needs and challenges.
I think physicians want to know this type of information, but it can be really overwhelming for them to ask themselves. If it’s already in the EHR, they can go in, review it and get a better idea of who the patient is.
What do you see as some of the current challenges in capturing SDOH data?
Many EHRs already capture basic demographic information. But it’s important that we go beyond that. I’ve been a part of a group that is working on how to expand the information collected in Ontada’s EHR, iKnowMedSM, and we’re excited to start rolling out new updates that will allow for greater insights into SDOH data.
One challenge in collecting additional information about a patient is that there are sensitive topics such as trauma or domestic violence, and you have to be careful about what is documented. Additionally, patients have to be comfortable sharing this information. A social worker is trained to have these conversations, but other staff may not be equipped with the same skillset and may not be as comfortable gathering this information.
It will also be interesting to see how the data capture evolves, because everyone has their implicit biases, and we will have to consider if and how those biases might impact how we record information and how patients are treated.
How do you see SDOH data being used to shape patient care in the future?
From a data perspective, there are a lot of research opportunities to identify trends within patient populations.
And from a social work perspective, there is the potential to help patients in more significant ways. As you learn more about a patient, there is tremendous opportunity to make an impact in a patient’s life by having one-on-one conversations, beyond that of the diagnosis at hand.