Addressing Health Disparities & Social Determinants of Health (SDOH): The Path to Health Equity, Part 2
The following is part 2 of 5 in a series of articles titled, "The Path to Health Equity" by Jason Ausili, PharmD, MSLS, Head of Pharmacy Transformation for EnlivenHealth, as well as other contributors to Ask Your Pharmacist.
In the evolving landscape of healthcare, the role of pharmacists is rapidly expanding beyond medication management. Today, community pharmacists provide a number of services in addition to filling prescriptions, including immunization, point-of-care test and treat services, diabetes prevention and self-management training, tobacco cessation, and more. And while these additional services are both needed and appreciated by communities all over the country (particularly those in medical deserts), there's still more to be done.
The path to health equity is paved with more than just healthcare. There are other factors that contribute to the health of an individual and the health of a community as a whole. And in order to know how we should address those other factors, we first have to acknowledge and address health disparities.
What Are Health Disparities?
Health disparities refer to the differences in health outcomes and their determinants between segments of the population. These differences can be based on race, ethnicity, socio-economic status, gender, or geographic location. Health disparities are often linked to social, economic, and environmental disadvantages, making them a key focus for improving overall community health.
For example, the LGBTQ+ community faces health disparities when compared to their non-LGBTQ+ counterparts. According to a KFF article, LGBTQ+ people have higher rates of ongoing health conditions, disability, and chronic disease. They often report negative provider experiences and are less likely to discuss certain health and social issues with medical professionals, often because they feel the provider blames them or their lifestyle for their health issues. Plus, LGBTQ+ people are more likely to have financial issues that would prevent them from paying medical bills, also making it less likely that they would seek out health services even if needed.
If health equity is the goal, then health disparities are the gaps that keep us from reaching that goal. And the mechanism we use to identify, assess, and address health disparities are called social determinants of health.
The Impact of Social Determinants of Health (SDOH) on Health Outcomes
When discussing health equity and health disparities, social determinants of health are the elephants in the room. These are the factors outside of dedicated healthcare that present barriers to achieving optimal health.
Social determinants of health (SDOH) have a profound impact on health outcomes — an impact often greater than that of medical care. According to a 2022 report from the ASPE Office of Health Policy, clinical care impacts only 20 percent of county-level variation in health outcomes, while social determinants of health impact as much as 50 percent.
The conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes. For example, a person's income would be considered an SDOH; if someone can't afford their medications or healthy food, they will likely be in worse health than someone who is adherent to their medications and regularly eats healthy. Factors like education and housing also play a part.
The Five Domains of SDOH
Social Determinants of Health can be divided into five key domains. According to the U.S. Department of Health and Human Services, these domains are:
Economic Stability: Poverty is a major problem in the United States, and it can have a negative impact on health. People with steady employment are less likely to live in poverty and more likely to be healthy. Employment programs, career counseling, and policies to help people pay for basic necessities can help reduce poverty and improve health.
Education Access & Quality: People with higher levels of education are more likely to be healthier and live longer. Children from low-income families, children with disabilities, and children who experience social discrimination are more likely to struggle in school and have health problems later in life. Interventions to help children and adolescents do well in school and help families pay for college can have long-term health benefits.
Health Care Access & Quality: Many people in the United States do not have access to timely, high-quality healthcare services. This is due to a number of factors, including lack of health insurance, lack of access to healthcare providers, and lack of transportation. Strategies to increase insurance coverage rates, improve access to healthcare providers, and improve communication between patients and providers can help more people get the care they need.
Neighborhood & Built Environment: The places where people live, work, play, and learn have a major impact on their health and well-being. People who live in neighborhoods with high rates of violence, unsafe air or water, and other health and safety risks are more likely to experience poor health. Interventions and policy changes at the local, state, and federal level can help reduce these health and safety risks and promote health.
Social & Community Context: Social support can have a major impact on people's health and well-being. People who have strong social support networks are more likely to be healthy and have a sense of well-being. Interventions to help people get the social support they need are critical for improving health and well-being.
Legislation & Other Actions Helping to Reduce Health Disparities
Far-reaching problems require far-reaching solutions. To counter health disparities among the population, the federal government has passed legislation and created programs in recent years that aim to not only expand healthcare coverage and access, but also encourage providers to look outside the traditional methods for addressing and improving community health.
The Affordable Care Act (ACA) expanded health insurance coverage to millions of Americans, reducing the number of uninsured people and improving access to care. The ACA also includes provisions to address health disparities, such as funding for community health centers and programs to improve care for people with chronic diseases.
The Community Health Needs Assessment (CHNA) requires hospitals and health systems to assess the health needs of their communities and develop plans to address those needs. The CHNA process can identify opportunities for community pharmacies to play a role in addressing health disparities.
The 340B Drug Pricing Program provides discounts on prescription drugs to certain health care organizations, including community pharmacies. These discounts can be used to provide free or reduced-cost medications to patients in need.
The Pharmacy Quality Alliance (PQA) provides tools and resources (including a comprehensive SDOH resource guide) to help community pharmacies improve the quality of care they provide. The PQA includes a number of initiatives that focus on addressing health disparities, such as the Diabetes Care Improvement Initiative and the Medication Therapy Management Program.
In addition to programs that are already active, there are still pending legislative acts and proposed programs out there that could benefit millions of people with enough support:
The Equitable Community Access to Pharmacist Services Act would allow community pharmacies to provide a wider range of preventive services, such as vaccinations, testing and treatment for acute conditions for COVID-19, flu, RSV, and strep throat. This would help to improve convenience and access to care for these services among the Medicare population.
The Pharmacy and Medically Underserved Areas Enhancement Act would allow pharmacists to bill Medicare for services they provide in underserved areas, including health and wellness screenings, immunizations, and diabetes management.
The Equal Health Care for All Act would establish equal access to healthcare as a protected civil right. This would help to improve healthcare and reduce mortality disparities among marginalized communities by targeting the racial inequalities and systemic failures in our health system.
The Role of Community Pharmacies in Addressing SDOH
Community pharmacies already play a vital role in the health of communities, but addressing SDOH could take that role even further. The following are ways that community pharmacies can address Social Determinants of Health in their patients and beyond:
Screening for SDOH: Pharmacists can screen patients for SDOH, such as food insecurity, housing instability, and transportation challenges. This information can help pharmacists to identify patients who may need additional support to manage their health.
Referral to community resources: Pharmacists can refer patients to community resources, such as food banks, transportation services, homeless shelters, and health education programs. (Many pharmacies use a service like findhelp.org to quickly find the resource their patients need.) These resources can help patients to address the SDOH that are contributing to their health problems.
Collaboration with other healthcare providers: Pharmacists can collaborate with other healthcare providers, such as doctors, nurses, and social workers, to develop comprehensive care plans for patients. Collaborative team-based care can help to ensure that patients are getting the care they need to address all of their health needs, including their SDOH.
Advocating for patients: Pharmacists can advocate for patients by educating policymakers and the public about the importance of addressing SDOH. They can also advocate for policies that support patients, such as expanding access to affordable housing and healthcare. Luckily, pharmacists and patients can get help from patient advocacy groups like the Patient Advocate Foundation and the Patient Access Network (PAN) Foundation.
During a recent EnlivenHealth webinar, Stephanie McGrath, PharmD, from the Pennsylvania Pharmacists Care Network (PPCN) highlighted just how much of a difference community pharmacists can make. Over a 7-month period, PPCN pharmacies (in partnership with one health plan) performed 1,129 SDOH screenings, with 28.6% of those screenings resulting in a referral to address an identified gap. Gaps identified included financial strain, home utilities, food insecurity, housing, transportation, and more.
"This is a huge opportunity for our pharmacy teams to really make a difference with patients to help identify needs, help overcome those needs, and allow those patients to focus more of their time and resources on taking care of their health," said McGrath.
Removing the Barriers
All people — regardless of background, race, gender, or financial status — should have an equal opportunity at achieving healthy outcomes. Community pharmacists have the power to make a difference in the lives of the marginalized and remove the barriers to health equity. It's time to look beyond treatment plans and prescriptions, and look a little closer at the world our patients live in.
NEXT — Part 3: Improving Access to Care »