July 23, 2018

How do you handle social determinants?

By: Elizabeth Wood

Social and demographic factors play a huge role in any patient’s overall health and recovery from surgery. When treating patients who lack health insurance, family support, or language/literacy skills—among many other possible disadvantages—providing safe patient care can extend well beyond clinical aspects. OR managers and their staffs may take on tasks ranging from arranging for transportation to managing ethical dilemmas.

Healthcare leaders will offer their insights during the annual OR Manager Conference. Jacob Runion, MBA, BSN, RN, CNOR, director of nursing at the Cleveland Clinic, and Janet Duran, DNP, MSN, MHA, RN, perioperative director at Fairview Hospital and ASC, a regional hospital of the Cleveland Clinic, will discuss “The New Reality We Face: Addressing Social Determinants in the Surgical Suite” on September 18.

The social determinants of health described in Healthy People 2020 (p 9) encourage healthcare to create good health for all. However, “social determinants have become a developing problem for the past several years,” Duran says. “One determinant that has signifcantly impacted perioperative patient care is the opioid epidemic, which has made it challenging to provide medication for pain management and high-quality, equitable patient care.”

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What are social determinants?

According to Healthy People 2020, social determinants broadly include:

• economic stability

• education

• social and community context

• health and healthcare

• neighborhood and built environment.

More specifically, factors such as gender, sexual identity and orientation, language and religion, nationality, immigration status, legal status, exposure to violence, and housing security also factor into a patient’s health and well-being.

“We’ve been hearing more about social determinants of health through our work with accountable care organizations [ACOs],” says Amy L. Bethel, MPA, RN, NE-BC, clinical professional development and manager, eye surgery, UnityPoint Health, Des Moines. “Terms such as ‘population health’ and ‘transitions of care’ have become more mainstream.” With payment models changing from fee for service to value-based care, it is increasingly important to consider the impact of social determinants on outcomes, she adds.


Who is responsible?

Amy L. Bethel, MPA, RN, NE-BC

“Increasingly, health systems are asking, ‘who’s going to pay for social determinants of health?’” Bethel says. “Patients who are homeless, drug addicted, or have poor support at home are at high risk for readmission. Is the cost of managing social determinants going to shift from the government or payers to health systems? Value-based care is all about keeping people well, but if they have social determinants that are barriers to them being healthy, whose responsibility is it to manage those?”

A 2017 survey on social determinants administered by the healthcare consulting firm Leavitt Partners asked physicians which factors would “greatly or moderately” benefit their patients. Among the 621 respondents, their answers were:

• helping patients arrange for transportation (cited by 66%)

• increasing patients’ income (54%)

• helping them get sufficient food (45%)

• helping them get affordable housing (45%).

However, most physicians said they did not believe it was their responsibility to address these issues.

In a comment on these findings, The Advisory Board says, “…the primary responsibility for addressing social needs is often held by non-physician staff who are involved in discharge planning, transition support, and ongoing care management. The RN care managers, social workers, community health workers, and others who typically own this task can tap into their relevant expertise and thereby help physicians focus their limited time on clinical care.”


Someone has to do it

Runion and Duran can attest to the fact that managing at least some of patients’ social needs falls on the shoulders of the perioperative services staff. They have taken charge of everything from arranging for transportation to finding interpretive services for patients who don’t speak English.

“Frequently surgical patients are dropped off by bus or by friends hours before their surgical procedure,” Duran says. “When assessing their needs preoperatively, we find there is not a responsible caregiver to drive them home or take care of them when dischage criteria are met. Often they ask to stay for hours because of transportation issues and the responsible caregiver’s schedule. In some instances, we have assisted in arranging for transportation for the patient and the responsible caregiver when they have identified transportation needs after surgery.”

Lack of support at home to help patients recuperating from surgery has also been identified as a social determinant, she says. For example, surgical patients may need to rely on a spouse for caregiving after surgery, but what happens when that spouse isn’t able to serve as a caregiver?

Bethel has experienced similar problems at UnityPoint. “We have a policy that we are not allowed to send patients home via taxi, Uber, or any public transportation,” she says. Sometimes surgery is canceled because there is no one to drive the patient home afterward.

Making sure patients have a responsible caregiver is important, she adds. “Some patients may have cognitive problems, for example, so they need to have someone who can help them administer their eye drops.”

There are many other types of support services or even basic tools that patients may be lacking, Bethel notes, such as a scale at home to weigh themselves. She recalls when UnityPoint realized that some of their heart failure patients couldn’t properly track their weight, the facility ended up buying scales for home use.



Social determinants have changed the way preoperative assessments are done, Bethel says. For example, her facility has a high population of diabetic patients, and the diabetes isn’t always well managed. “We have to monitor their preoperative blood sugar to determine if they’re a good candidate for surgery,” she says.

“You have to think about what will affect outcomes,” Bethel says. “The surgical experience is an episode in the continuum of care, and sometimes we don’t spend a lot of time with these patients, so how do you make meaningful interventions?”

Health literacy is another thing to consider, she notes. Do patients understand discharge instructions? Can they read and write? “Our organization has looked at consents, home instructions, any patient literature—we’ve been evaluating it from the health literacy perspective. Is it easy to understand?”

Under federal law, interpretive services must be offered to patients who don’t speak English. Bethel notes that family members sometimes want to interpret for their loved ones, but to do so, they must sign a waiver. And, by law, an interpreter must be involved when such a waiver is signed. “It’s an important process, but one that can take time to manage,” she says.

Communicating across departments is very important, Bethel says. “We have a document in Epic called Transitions of Care that pulls information from the episode of care. This information is viewable by others who may be caring for the patient,” she says.

The Cleveland Clinic has similar documentation in place through the electronic medical record. The individual plan of care creates a workflow and care pathway that is discussed with the patient, Duran says. This plan of care, once established, is followed at any Cleveland Clinic hospital. In the case of a patient who is an opioid abuser, she says, the plan of care supports appropriate medication management throughout the patient’s perioperative stay.


Getting surgeons on board

In 2015, the American College of Surgeons and the National Institutes of Health convened a summit with 60 leading researchers and clinicians. They defined the following as top research priorities:

• improving patient-clinician communication

• fostering engagement and community outreach through technology to optimize patient education, health literacy, and shared decision making

• improving care at facilities with a higher proportion of minority surgical and trauma patients

• evaluating the longer-term effect of acute interventions and rehabilitation support within the critical period of injury or illness on functional outcomes and patient-defined perceptions of quality of care

• improving patient centeredness by identifying expectations for postoperative and postinjury recovery.

Several studies have linked oral nutrition supplements with shorter length of stay (LOS), lower cost of care during hospitalization, and reduced risk of readmission.

Delving into this more deeply, researchers led by Krishnan Sriram, MD, at Advocate Health Care in Downers Grove, Illinois, compared the impact of a nutrition quality improvement program (QIP) on surgical vs medical patients.

They enrolled 1,269 patients in the QIP (288 surgical and 981 medical patients). The QIP, implemented at two teaching hospitals and two community hospitals, consisted of malnutrition risk screening at admission, starting oral nutrition supplements for at-risk patients, and providing nutrition education for inpatients and caregivers.

The 30-day readmission rates dropped from 22.3% to 17.7% for medical patients and from 19.6% to 10.4% for surgical patients, the authors say. Similarly, LOS dropped from 7.1 days to 5.0 days for medical patients and from 9.3 days to 6.6 days for surgical patients.

Noting that just 43% of US surgeons screen patients for nutrition before gastrointestinal or cancer surgery, the authors conclude with a “call to action” for surgeons to raise awareness of the importance of nutrition on surgical outcomes, partner with hospital administration to obtain appropriate support for nutrition care processes, and to expand nutrition education and training in residency and continuing medical education programs.

Other researchers have investigated healthcare disparities in patients of otolaryngologists—a specialty that has not commonly focused on this problem. Regan W. Bergmark, MD, and Ahmad R. Sedaghat, MD, PhD, of the Massachusetts Eye and Ear Infirmary and Harvard Medical School in Boston, project that social determinants of health will be increasingly important for reimbursement.

“While many ACO outcomes measures currently focus on chronic medical diseases or common medical conditions, there will likely be increasing emphasis on surgical outcomes and management,” they say.

Patients with low socioeconomic status, they say, are more likely to be exposed to disease risk factors and less likely to get healthcare. That means they may more often get infections that progress rapidly from lack of treatment.

Similarly, patients who either lack health insurance or rely on Medicaid have worse outcomes than those with private insurance or Medicare, they note. For example, they cite a study showing that such patients presented with more advanced medullary thyroid cancer at the time of diagnosis. In addition to the lack of early access to care, these patients may have language and cultural barriers.

They conclude with a plea for their specialty to take a leadership role in rectifying disparities. “From rhinosinusitis to hearing loss to sleep apnea to cancer, the conditions that we manage impact millions of individuals and lead to billions of dollars of healthcare spending every year,” they say. Improving healthcare access and insurance coverage could improve the bottom line and reduce social disparities, they note.

In June 2018, the American Medical Association (AMA) adopted a policy to define health equity and outline a strategy leading to optimal health for all through dedicated resources, staff and budget, and a multiyear programmatic roadmap.

“In this era of value-based purchasing and rewarding outcomes, it’s the right thing to do to manage social determinants of health. But the reality is, it does affect payment, so it’s really important to manage this on the front end,” Bethel says.

”The perioperative setting isn’t exactly where one would think social determinants impact care delivery,” Runion says. “However, it is imperative that we educate each other and our caregivers about its impact in our arena.” ✥



Advisory Board. More than 80% of doctors say it isn’t their job to fix social determinants of health. (But that’s not quite as alarming as it seems.) The Daily Briefing. May 15, 2018. https://www.advisory.com/daily-briefing/2018/05/15/social-determinants.

Haider A H, Dankwa-Mullan I, Maragh-Bass A C, et al. Setting a national agenda for surgical disparities research: Recommendations from the National Institutes of Health and American College of Surgeons Summit. JAMA Surg. 2016;151(6), 554-562.



Sriram K, Sulo S, VanDerBosch G, et al. Nutrition-focused quality improvement program results in significant readmission and length of stay reductions for malnourished surgical patients. J Parenter Enteral Nutr. Published online February 2, 2018.

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