Virginia Nurses Today 2_20

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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
www.VirginiaNurses.com | Virginia Nurses Today February, March, April 2020 | Page 13 SDOH needs that affect adherence, access and overall health? Connecting individuals to appropriate resources, public and private, will follow from the nurse’s assessment and identifying SDOH needs will improve health and address health disparities. Early referral to a social worker or case manager offers immediate intervention for a myriad of public, private and charity resources. Any offered resource that has restrictive requirements, or is inconvenient, will be less valuable to an individual and their family/caregiver. Examine the available resources in your organization such as a central community referral center where the gap between clinical care and community services can be addressed. Embedded public benefits workers who assess eligibility and offer enrollment on-site streamline the application process thus lessening the burden, and stigma, of enrollment. What about sending discharged patients home with food? Medications from a medical pharmacy; food from a food pharmacy? Sentara CarePlex Hospital in Hampton, VA offers a Food Pharmacy, in partnership with the Virginia Peninsula Food Bank, that provides comprehensive care to heart failure patients. How about discharging identified patients with three days of groceries? Or offering one week of home delivered meals? Collaboration between hospitals, clinics, community resources and health plans are successfully addressing food, transportation and loneliness/isolation. One, or all, of these challenges may result in hospital readmission or impact a person’s self-care ability. Collaborating across service lines to create a meaningful resource directory that is transparent to all users is essential to addressing SDOH. Transitions of care occur 24/7, 365 days a year so all healthcare professionals appreciate a comprehensive resource. Colleagues in all settings have their “go to” people, providers and agencies. Merge those contacts into a “resource bank” that is critical outside of regular operating hours or when a social worker or case manager may not be readily available. Update the directory as often as needed to provide accurate points of contact, locations, etc. Know your community. Not just where you live but the entire service area of your organization. Take a drive and be aware of your surroundings. What do you see on your commute? Be familiar with what faith communities and other non-profit agencies offer. Faith communities with farmer’s markets, transportation assistance and health clinics are available to serve their localities. Appreciation and comprehension of what your patients, or customers, experience is both enlightening and essential to their health and wellness success. Facilitating and offering resources is 50% of the equation. The remaining initiative is on the individual/family/caregiver. Therefore, it’s sensible to offer resources that are specific to their needs. Just giving a phone number may not empower someone into action. A point of contact, established appointment or assistance with required documentation personalizes the assistance and demonstrates that nurses meet people where they are and recognize individual concerns. What’s Next? As the interest in incorporating SDOH for a more comprehensive view of patients is addressed, community initiatives are dependent on local funding and sustainable dollars. Success depends on convincing the community and other stakeholders that health disparities and inequities are related to SDOH. SDOH can account for up to 40% of individual health outcomes (Booske, 2010). That’s a significant number in our healthcare environment where patient-centered care, the patient experience and quality of life are identified imperatives. On the federal level, the Centers for Medicare and Medicaid Services (CMS) wished to address the connection between medical services and social needs. Accountable Health Communities is a $157 million test payment mode, funding pilots, which ask does addressing health-related social needs reduce healthcare costs and utilization. Also, CMS developed a 10-item screening tool to identify patient needs in five different domains. The tool is designed to be short, accessible, consistent and inclusive. The domains are housing instability, food insecurity, transportation needs, utility needs and interpersonal safety (CMS, May 30, 2017). SDOH influence readmission risk, increased utilization and affect health outcomes. The National Academies of Science, Engineering, and Medicine, acting on a request from the Department of Health and Human Services, convened to examine the SDOH elements that could be considered for Medicare accounting purposes, criteria to identify these factors, and methods to do so in ways that promote health equity and improve care for all patients (National Academies of Sciences, Engineering, and Medicine, 2017). Medicare Advantage plans are adding SDOH assessments and benefits such as gym memberships, home-delivered meals and friendly visitors. Addressing SDOH with dual eligible Medicare recipients, those that qualify for Medicare and Medicaid, reveals that these patients have poorer outcomes such as higher healthcare utilization, higher healthcare spending, and lower quality measure scores. Dual recipients report lower educational attainment, a key SDOH. (Heath, 2019). More than half of dual recipients live in a neighborhood where at least 20% of its inhabitants live below the poverty level. Non-dual eligibles experience better health, are more likely to have higher education and are less likely to live with diabetes, hypertension, heart failure or depression. Other population-focused SDOH challenges are experienced by the LGBTQ community, disabled persons, homeless veterans and those living with mental illness. Their healthcare may be impacted by stigma and being a marginalized, vulnerable individual. These individuals may have lower incomes, fewer resources and complex health conditions which when complicated with SDOH result in poor health outcomes. Sensitivity to individual experiences and needs is critical to offering a superior patient experience. Across our nation, partnerships are developing to address SDOH. Many are between healthcare organizations and community agencies. One example is the local Agency on Aging and a community hospital where they are addressing the needs of older adults. Another is the Community Service Board partnering with law enforcement and the hospital emergency department for behavioral health intervention. Other grassroot efforts focus on specific needs with individual neighborhoods such as street lighting, bike lanes and playgrounds. Consider where people are born, grow, live, work and play. Broadening nurses’ knowledge and skills to include factors outside of traditional healthcare services will truly address areas that impact selfcare and healthy living. References Alley, D., Asomugha, C., Conway, P. et al. (2016). Accountable health communities-Addressing social needs through Medicare and Medicaid. http://www.nejm.org/ doi/full/10.1056/NEJMp1512532National Booske, B.C., Athens, J.K. et al. (2010). Different perspectives for assigning weights to determinants of health. University of Wisconsin Population Health Institute. Centers for Disease Control and Prevention (CDC) (2015). Community health assessment & health improvement planning. https://www.cdc.gov/stltpublichealth/cha/ index.html Centers for Medicare and Medicaid Services (CMS), (2017). Standardized screening for health-related social needs in clinical settings. https://nam.edu/wp-content/ uploads/2017/05/Standardized-Screening-for-Health- Related-Social-Needs-in-Clinical-Settings.pdf Fink-Samnick, E. (2019). The Social Determinants of Health: Case Management’s Next Frontier. HCPro: Brentwood, TN. Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., & Frank, D. A. (2010). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126(1), e26-e32 Healthy People 2020. United States Department of Health and Human Services. https://www.healthypeople. gov/2020/topics-objectives/topic/social-determinantsof-health Heath, S. (2019). Most Medicare dual-eligibles see social determinants of health. Accessed at: https:// healthpayerintelligence.com/news/most-medicare-dualeligibles-see-social-determinants-of-health Institute of Medicine (March 2016). A framework for educating health professionals to address the social determinants of health. The National Academies of Sciences-Engineering-Medicine. http://national academies.org/hmd/reports/2016/framework-foreducating-health-professionals-to-address-the-socialdeterminants-of-health.aspx National Academies of Sciences, Engineering, and Medicine, (January 10, 2017). Accounting for social risk factors in Medicare payment. http:// nationalacademies.org/hmd/reports/2017/accountingfor-social-risk-factors-in-medicare-payment-5. aspx?_ga=2.218029013.2138807034.1515360046- 1035669673.1515360046 The Human Toll of Jail (2016). Incarceration’s impact on kids and families. http://humantollofjail.vera.org/thefamily-jail-cycle/ World Health Organization, Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health equity through action on the social determinants of health. Available from: http://www.who. int/social_determinants/en Join Our Clinical Team at Compassus, You’ll Remember Why You Do What You Do! Now Hiring RNs & LPNs Northern Virginia to Fredericksburg If you are passionate about impacting patients’ lives through compassionate hospice and palliative care, a position on our team may be perfect for you! We offer medical benefits, 401(k) with company match, generous PTO, and more lucrative benefits! Visit our website to learn more about our amazing culture and commitment to our patients and their families, and to apply for our open positions: compassus.com/careers
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