It’s a fact beyond question for most doctors: Determining whether a child is homeless, goes hungry or has impoverished, stressed-out parents is nearly as important as taking a young patient’s vital signs in the examination room.
To Dr. R. Lawrence Moss, it’s evidence that the system of pediatric care in the U.S. is upside down. In many ways, he says, social determinants of health — a child’s neighborhood, household income, parental education level and other factors — are more critical than temperature, height and weight in determining a patient’s level of health.
“More than 80% of health is due to these factors and not medical care,” Moss told an audience Monday at the U.S. News & World Report Healthcare of Tomorrow conference in Washington, D.C. That these factors are treated as secondary to medical care, he says, is “sort of an irony” because social determinants of health “is what it’s all about — it is the ballgame.”
Moss, president and CEO of Nemours Children’s Health Systems, was part of a panel discussion, “How Children’s Hospitals Can Make an Impact on the Social Determinants of Health.”
Moderated by Dr. Rajan Wadhawan, a pediatrician and an AdventHealth senior executive, the panel included Moss and two pediatricians, Dr. Tamarah Duperval Brownlee, senior vice president and chief community impact officer of the Ascension Health network, and Dr. Jean L. Raphael, director of the Center for Child Health Policy and Advocacy, Texas Children’s Hospital. Tim Robinson, CEO of Nationwide Children’s Hospital, also joined the panel.
Defined as the conditions in which people are born, are educated, work, live and age, social determinants of health have become increasingly important to the medical industry. Study after study has linked environment to health, particularly among children and adolescents, whose bodies and brains are still developing and highly influenced by surroundings. Some estimates suggest unstable housing or food insecurity costs the nation billions of dollars a year in avoidable medical and treatment bills.
As a result, caregivers have begun to focus on “upstream” factors like housing, food and exposure to violence when evaluating young patients. Some doctors have even begun writing “prescriptions” for things like healthy food to help improve patients’ health. Wadhawan and the four panelists all agreed that social determinants of health are important and should be part of patient evaluations.
Moss was the most bullish on linking factors outside the examining room to a patient’s health, and said not many patients or physicians are making the connection.
Statistics from the Robert Wood Johnson Foundation, a health data organization, and other reputable sources underscore his point, Moss said: A quarter of all parents raising young children are food insecure, 1 in 5 parents are concerned about their children’s safety, and 65% of families believe adult lifestyles in the home play a role in the health of young people.
Yet only about 3 in 10 parents “ever recall being asked about safe housing, access to food, exposure to violence,” Moss said. “Over two-thirds of all parents want their doctor to be a convener” and point them towards resources to help with their social issues, he said.
But determining a patient’s socioeconomic needs can be a minefield for doctors, Raphael said. Besides making patients or their families uncomfortable, questions about abuse in the home, food insecurity or unstable housing can have unintended consequences — including patients feeling stereotyped, or physicians taking on roles better left to social workers.
“There is the potential that they may not be able to get those services” for their patients, Raphael said. Though there’s “momentum” around screening for patients’ social and economic needs, he said, there’s no hard data proving it improves health; instead, it adds to a doctor’s workload and can be a distraction from providing focused care.
Brownlee, however, noted that several hospitals in her network routinely screen child patients for problems apart from the symptoms they may present during an examination, and try to connect patients with outside services that can help them and their families — including meeting spiritual needs of patients. And Robinson says Nationwide has integrated a “multi-pronged” approach, integrating social services into its evaluations of children as well as the surrounding communities.
That includes partnerships to repair dilapidated homes and provide stable, subsidized housing for children — and perhaps job training for unemployed or underemployed parents, Robinson said.
While the panelists agreed on the need to incorporate screening tools into patient evaluations, Moss said success in such initiatives is a paradox: The more successful those tools are in identifying hunger, homelessness, poverty and instability, the less doctors and other health care providers will need to use them.