Despite clinicians focusing on evidenced-based interventions, Americans continue to get sicker. One key underlying cause is the underinvestment in time and resources in social determinants of health (SDoH) ─ conditions based on where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
Numerous studies suggest that SDoH factors account for between 30-55% of health outcomes, the lower an individual’s socioeconomic position, the higher their risk of poor health. However, because the U.S. health system has largely ignored the impact of SDoH, we have reached a critical tipping point with far too many marginalized people disproportionally facing health disparities.
To fully impact health outcomes and costs long-term, providers must optimize population health management and wellness at scale.
Marginalized and disadvantaged populations have traditionally accessed care through community health centers (CHCs). Since their inception in the 1960s, providers working at more than 1,400 CHCs have acknowledged that where we live, work, worship and play affects our health. Indeed, who would be better than experts at these health centers to reach beyond the clinic walls to address the health and well-being barriers their patients face?
Most organizations recognize that patient engagement is a critical part of the solution for CHC outreach, especially in rural and vulnerable urban areas. By leveraging conversational artificial intelligence (AI) tools, providers can connect online to their patient communities en masse, identifying at-risk patients, and addressing health disparities.
Millions of the people covered by community health centers do not engage in recommended preventive healthcare services. Community health center patients differ demographically from the total U.S. population and even from the low-income U.S. population. In part, the differences reflect their specific statutory mission to serve medically underserved communities and populations.
CHC patients typically have multiple SDoH barriers. They are older adults who are more likely to be working age, unemployed or underemployed, uninsured, have low income, and may be living below the poverty line. Racially and ethnically diverse, English is predominately their second language. They are in poor health, have substantial health burdens with one or more chronic diseases, which are exacerbated by higher health risk factors such as smoking and obesity.
SDoH factors can and often do impact clinical outcomes more than medical factors. Ironically, while the U.S. spends a higher percentage of its gross domestic product on medical care expenditures than other developed countries, many other developed countries proportionally spend more on social services.
Patient data analysis and primary care providers integrated into public services, are the backbone of the population health management model. For community health centers, primary care providers offer a regular source of care, providing early detection and treatment of disease, chronic disease management, and preventive care. Patients with a reliable source of care are more likely to receive recommended preventive services such as flu shots, blood pressure screenings, and cancer screenings.
Unfortunately, many people face barriers to accessing primary care services, which increase the risk of poor health outcomes. Some of these obstacles include lack of health insurance, language-related barriers, disabilities, inability to take time off work to attend appointments, geographic and transportation-related barriers, and a shortage of primary care providers.
Other SDoH challenges that impact primary care access include:
1) Household stability in terms of income, access to nutritious food and physical activity opportunities, safe housing, employment, and transportation.
2) Education to overcome English language comprehension, knowledge of healthcare services and resources, and overall literacy levels. Patients may be unaware of standard preventive health practices, including recommended vaccines, well-baby and well-child visits, cancer screenings including mammograms and colonoscopies, and counseling on topics such as nutrition to manage diabetes or how to quit smoking.
Healthcare professionals understand the importance of patient access to regular primary care services. Increasingly, they are proactively recognizing and addressing social determinants of health barriers, working with their CHCs to ensure patients get the care and resources that they need to thrive.
Current challenges when screening for SDoH include:
Sadly, due these barriers and more, only 10-25% of patients schedule an annual wellness visit. Given that physicians use wellness visits to address most gaps in care, managing only patient-initiated visits makes it difficult to impossible to achieve population health goals.
Investing in a digital communication platform is a proven way to address these dilemmas, helping to increase annual wellness visits and to identify and address SDoH barriers. Here are six ways to increase engagement:
A health center-controlled network (HCCN) and practice-based research network sought to close gaps in patient care using QliqSOFT’s all-in-one patient engagement solution. Deploying the platform’s patient-centered chatbot, the HCCN successfully transformed primary care delivery for a community health population.
Real-time, two-way chatbot conversations in English and Spanish proactively engaged patients overdue for preventive screenings and primary care services. The chatbots enabled screening for SDoH in a manner that respected patients’ privacy and eliminated workflow challenges. On average, 27% of patients receiving a chatbot engaged and scheduled preventive care services, potentially doubling or more the performance of the CHC providing care compared to only to those who independently seek care.
Summarized below are patient response rates to the HCCN’s SDoH screening questions. The positive impact of patient engagement and interventions facilitated significant improvements in scheduling health services, such as well-child care visits and immunizations, cancer screenings (mammograms and colonoscopies), and enrollment in remote blood pressure monitoring.
“It [feels like you are] showing more concern [about] the patient and with everything happening in the world with COVID I am happy [you]'re showing concern.” - Patient Survey Response
Proactive digital patient engagement outreach motivates consumers to participate in their own healthcare journey. The AI technology is cost effective, patients appreciate it, and it works.
Bobbi is a lifelong learner who is passionate about enabling healthcare transformation. She has 20+ years of healthcare experience in care delivery, consulting, healthcare IT, and market strategy.
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