Virginia Nurses Today 2_20

Page 12 | February, March, April 2020
Continuing Education
Virginia Nurses Today | www.VirginiaNurses.com
Social Determinants of Health:
The Zip Code is the Most Important Number on the Patient’s Chart!
Disclosures
• Nurses can earn 1 nursing contact hour for
reading Social Determinants of Health: The
Zip Code is the Most Important Number on
the Patient’s Chart. Participants must also
complete the continuing education post-test
found at: https://virginianurses.com/page/
On-DemandContinuingEducation
• This continuing education activity is FREE
for members and $15 for nonmembers!
• The Virginia Nurses Association is
accredited as a provider of nursing
continuing professional development by the
American Nurses Credentialing Center’s
Commission on Accreditation.
• No individual in a position to control
content for this activity has any relevant
financial relationships to declare.
• Contact hours will be awarded for this
activity until February 15, 2023.
• Disclaimer: The opinions expressed here
are solely the author’s and do not represent
those of the United States Government, the
Department of Defense, or the United States
Navy.
Elaine Bruner, MSN, RN-BC
Author Bio
Elaine received her BSN
from the State University
of New York at Plattsburgh
and MSN from the University
of Virginia. Her nursing
practice has included
oncology, nutrition support/
home infusion, home health/
community-based services
and physical rehabilitation.
Elaine has more than 15
years of case management
experience and received Nursing Case Management
certification/ANCC, in 2002. She is a member of the
Hampton Roads and Alamo Case Management Society
of America (CMSA) chapters. Elaine also serves as
Immediate Past President of the Hampton Roads
Case Management Society (HRCMS) and as the 2015
HRCMS chapter conference Chair. Currently, she is
faculty for the Nurse Case Management reviews with
the ANA/American Nurses Credentialing Center and
co-authored Nursing Case Management Review and
Resource Manual (4th ed.) with Margaret Leonard.
Her publications include manuscripts in Home Health
Care Nurse, Home Health Care Advisor, Case In Point,
CMSA Today and The Case Manager. Elaine has been
faculty for national, state and regional meetings on
home health care and case management topics. She
serves on the Virginia Nurses Association Commission
on Nursing Education and the CMSA Nominating
Committee. In 2008, she was selected for the Award of
Service Excellence from the CMSA. Elaine is honored
to be the nurse case manager with Navy Special
Warfare, Virginia Beach.
Introduction
Challenged by high need, high cost patients
who struggle with adherence and self-care? Too
often the lack of healthcare funding may not be
the primary challenge for people as they live with
chronic illnesses, struggle to secure preventive care
or survive a catastrophic injury. Historically, our
healthcare and social service delivery systems are
not well-equipped to effectively manage patients with
multiple chronic diseases and complex social needs
such as food, housing, or substance abuse services.
In the November 1919 issue of the American
Journal of Nursing, Isabel M. Stewart shares “The
roots of disease are usually found in bad housing,
inadequate food, overwork and hundred other
causes…If a nurse is to help in the prevention of
disease, she has to get back to the unsanitary
conditions which produce disease.” And here we
are, 100 years later, asking how we can advocate,
educate, and facilitate the best healthcare for people
facing barriers that may not be captured in an
admission assessment or medical history/physical.
Consider the elements of a biopsychosocial
assessment and the valuable information available
by knowing where your patient lives, works, shops for
food or even exercises. These elements will positively,
or negatively, influence the transition of care/discharge
plan. Often the social determinants of health (SDOH),
impact a person’s ability for self-care more than
the diagnosis or available insurance. It is widely
recognized that the health of populations is often
determined by social factors other than health care.
SDOH can be the identified barriers for a seamless,
safe transition to self-care. Being knowledgeable on
the SDOH, identifying the actual, or potential barriers,
then deploying appropriate resources will enable
nurses to be a successful advocate for a patient’s
continued healthcare and services.
How are the SDOH defined? In 2008, the World
Health Organization defined social determinants of
health (SDOH) as the conditions in which people are
born, grow, live, work, and age. These circumstances
are shaped by the distribution of money, power,
and resources at global, national and local levels.
Consider the person with newly diagnosed diabetes
and their lifestyle modifications including diet and
exercise. How do they adhere to appropriate food
choices if they live in a food desert neighborhood
that lacks a full service grocery store? What about
exercise where there are no sidewalks or parks?
And to adhere to their primary care appointments
requires a two hour public bus ride, one-way.
These circumstances seem daunting to a healthy
person; imagine what it presents to someone with
limited functional abilities or financial resources.
Managing social determinants within population
health is critical to improving outcomes, closing
care gaps, and lowering the cost curve. Nurses
are well-positioned to identify the SDOH, increase
patient engagement by integrating SDOH to improve
adherence, offer better access, and promote health
equity.
The five domains that describe the SDOH are:
• Economic Stability such as available
employment; housing; and food security
• Education such as early childhood education;
high school completion; and job training.
• Neighborhood and Built Environment
such as environmental conditions; crime and
violence; and quality of housing.
• Health and Healthcare such as available,
accessible providers; and health literacy.
• Social and Community Context such as
discrimination; racism; and incarceration.
Healthy People 2020, www.healthypeople.gov
Assessment of SDOH
Assessing the SDOH means asking personal,
probing, and often delicate questions regarding a
person’s lifestyle, home environment, or finances.
Consider elements outside of traditional healthcare
questions when assessing barriers to self-care.
Early assessment, screening, and interventions are
imperative. Prepare by reviewing all available data
prior to meeting a patient/family/caregiver. There
may be statements that offer clues to non-adherence
such as “non-compliance with meds” or “no-show for
second scheduled appointment.” Nurses are poised
to assess elements that are not included in the
usual history and physical, yet present tremendous
barriers to patient adherence, self-care, and
healthy living. What questions will yield additional
information related to SDOH? Consider the
psychosocial issues that are currently reviewed such
as housing, income, support system. What about
food security, neighborhood crime, or incarcerated
family members? Each has an effect on a person’s
ability to self-manage a chronic health problem or
health emergency.
According to the United States Department of
Agriculture, one of eight people in the USA faces
food insecurity (USDA, 2019). To address food
insecurity, use the Hunger Vital Sign, developed by
Drs. Erin Hager and Anna Quigg in 2010; it offers
insight into a family’s ability to secure adequate
food. The Hunger Vital Sign identifies individuals
and families as being at risk for food insecurity if
they answer that either or both of the following two
statements is ‘often true’ or ‘sometimes true’ (vs.
‘never true’):
“Within the past 12 months we worried
whether our food would run out before we got
money to buy more.”
“Within the past 12 months the food we
bought just didn’t last and we didn’t have money
to get more.”
How about addressing crime and violence in a
person’s neighborhood? Are you comfortable asking,
“Do you feel safe walking in your neighborhood?”
What about the housing or built environment? Many
older housing developments may have lead paint or
asbestos in the building. Nurses can, and should,
ask the hard questions which yields information to
support interventions that improve healthy living.
Transportation is a barrier for people in many
locations. The issue is more than whether or not
the public bus stop is within walking distance.
Travel time, the number of transfers, or safe
locations are all considerations. In rural areas
without public transportation the challenges may
be access to private vehicles with licensed drivers,
fuel costs, and distance to healthcare providers.
The simple question, “How do you get to your doctor
appointments?” offers nurses clues to an individual’s
transportation access and its impact on other SDOH
such as grocery shopping or neighborhood safety.
The United States locks up more people per
capita than any other nation. Incarceration extends
to the children, families and communities who
must manage the social, financial and emotional
effects. Decreased income, lack of family support or
caregivers, plus the stigma of jail time have life-long
consequences. When a parent faces prison, their
children may go into foster care. Adverse Childhood
Experiences (ACEs) may include all types of abuse,
parental mental illness and incarceration. ACEs
impact future health and lifelong opportunity; learn
more at https://www.cdc.gov/violenceprevention/
childabuseandneglect/acestudy. When a parent
is imprisoned, the family finances may become
strained and the risk of homelessness increases.
Prison time may ban people with certain convictions
from receiving government benefits or subsidized
housing. Higher rates of incarceration tend to
occur in communities where poverty, violence and
increased police presence are seen. Jail takes a
tremendous toll on families and neighborhoods.
Learn more at http://humantollofjail.vera.org/thefamily-jail-cycle/.
A community health needs (CHN) assessment
offers critical data on a locality’s healthcare
service needs and issues through comprehensive,
systematic data collection and analysis. These
assessments, required every three years, identify
unmet community health needs and justify how and
where resources should be allocated to best meet a
location’s needs. Investigate your community’s CHN
for additional information, https://www.cdc.gov/
stltpublichealth/cha/index.html.
Intervention/Collaboration/Facilitation
How do nurses intervene when they identify