Panel Addresses the Social Drivers of Health


View the session recording. 

Today, we heard from a panel of colleagues discussing health's social drivers.

Panelists included Oke Anakwenze, MD, Associate Professor of Orthopaedic Surgery; Christian Pean, MD, Assistant Professor of Orthopaedic Surgery; Tyler Pidgeon, MD, Associate Professor of Orthopaedic Surgery; Susan Spratt, MD, Associate Professor of Medicine, Endocrinology; and, Erica Taylor, MD, Vice Chair for Equity, Diversity, and Inclusion; Chair; Assistant Professor of Orthopaedic Surgery.

The session began with Ben Alman, MD, chair of the Department of Orthopaedic Surgery, reminding us of the dramatic metamorphosis of our health institution's shifting from Duke Medicine to Duke Health.

He shared, "Health' is how you make a healthy society – and 'medicine' is what people get when ill or injured. There's a significant difference between medicine and health. That's why, in some parts of the world, they spend very little on medical care but a lot on health care and preventative health; as a result, they have such good health outcomes. So, this is a significant issue, and social needs are essential in providing good health, and making those changes can make critically positive outcomes in society. I thank our panel for speaking on these topics."

Christian Pean, MD: Addressing Social Needs in Orthopaedic Surgery: An Ethical and Economic Imperative

"We must acknowledge that we deliver unequal patient care nationwide. This needs to change because it is the right thing to do for our patients."

A recent quality improvement project at Duke Health revealed that Black patients were likelier to return to the Emergency Department after orthopaedic surgery without a difference in readmission rates.

"This highlights an opportunity. We should coordinate care better or increase patient education."

We have a lot of work to do – but how do we effectively move the needle? We have a lot of health care opportunities, but much less health. Over 60 percent of the factors that impact health are non-medical. Patients' lives outside the clinic drive most health outcomes. These social, behavioral, and environmental factors negatively affect readmission, hospital utilization, and chronic disease management.  

Tools are available to help medical professionals understand the health-related social needs of these populations and the social determinants of health (SDOH) that include–education and access quality, healthcare access and quality, built environment/neighborhood, economic stability, and social/community context. These are the factors we are going to screen for…

Some of you may feel removed from these factors; however, realize that the Centers for Medicare/Medicaid System (CMS) established a goal to have 100 percent of Medicare beneficiaries and most Medicare beneficiaries in accountable care relationships by 2030. Many companies are homing in on value-based care (VBC) enablement.

CMS Measure 1: Screening for SDOH
CMS Measure 2: Screen positive rate for SDOH

This will incentivize us to put patients in touch with community-based healthcare workers and put them in touch with those services that fill the gaps.

Healthcare's first attempt at social risk patient adjustment is the ACO REACH program. It tests a financing model to incentivize equity through federal and state governmental entities. Healthcare institutions must remain economically viable; we must focus on this concept.  

Pean concluded, "I will plug the Duke Orthopaedic Value and Equity (DOVE) initiative we are working on now. We can lead in this space with other medicine departments at Duke."

Susan Spratt, MD: Tools for Screening, Connection, and Evaluation

"I have been at Duke for 24 years as a diabetes doctor, and nowhere do I see social drivers impact patients more than in diabetic health. I jumped at the opportunity to address and prevent issues from developing and worsening at Duke in 2012. We needed a discrete way to capture SDOH information and pen it into their chart. Since Oct. 2018, you can find it in your EPIC storyboard, and it appears in red if it is positive for need of assistance. "

Later, in Jan. 2021, she explained that we began integrating into the NCCARE360 system. It's a statewide platform developed by the state's Health and Human Services Department that merges with our EPIC EHR and allows you to search for resources and send referrals. Everyone with a Duke email address has free access to NCCARE360. Since 2021, we have screened 230,519 patients. From that list, over 16.8 percent reported at least one health-related social need (HRSN). Conditions include housing, transportation, food, and financial.

On the storyboard in EPIC, you 'hover to discover' to learn more about each patient. The questionnaire can be offered on a pre-appointment electronic tablet.

Physicians need to realize that social drivers affect the health of their patients. This also requires buy-in from everyone to work as a team. This includes the front desk, rooming staff, and providers. Everyone plays a role in connecting patients to resources. Give our patients grace.

The best way to connect patients to resources is to refer them to DukeWell or the Duke Population Health Management Office (PHMO).

Since 2021, over 10,575 referrals have been run through the NCCARE360 platform. You can launch this platform through Maestro Care. We aim to work with the Compliance Office to automate these steps for patients and providers through EPIC ROSE by 2025.

Erica Taylor, MD: DHIP Diversity, Equity and Inclusion (DEI) Liaison Network – Translating Health Equity from Promise to Practice

"I am very proud of this moment. I consider this a milestone for our department. To see the evolution and where we are on this path and the fact that there is an entire Grand Rounds dedicated to social drivers of health and how we, as orthopaedic surgeons, can be part of the solution, and then think about how we're going to continue to sustain this in our spheres as we advance. Let's sit in this moment and recognize it."

How do we translate health equity from promise to practice?

The DHIP key priority areas in 2024 include:

  • Engagement and empowerment: promote 'connectedness to mission' for all clinical team members.
  • Measurement and metrics: Create relevant metrics to understand and visualize the current state and advance DEI goals.
  • Search and selection: communicate expected best practices for hiring processes consistently and effectively.

"I'm sharing this with you to tell you about it and hopefully to inspire you to start creating and innovating in this space. Instead of creating something new, I mirrored the Patient Safety Liaison program. What ended up happening over the matter of three weeks of my announcement is that we had all 127 ambulatory clinics participate in this program with an identified liaison."

The liaisons meet monthly for no more than one hour. They log on during the second Tuesday at 9 a.m., and we share a topic. Examples include policy or process updates across Duke Health and Rehab, and then we allow some volunteers to share clinic spotlights or best practices.

She added, "So, how can you contribute? "When you go out in the halls, what can you do? Number one is ambassadorship. Be able to articulate what you heard today to someone who was not here today. Maybe it won't be perfect, but don't shrug that you don't know. Please don't say we heard about something. Be able to replay this and learn this so that you can be ambassadors. That's how ideas and innovation get distributed. Support the clinical team."

It's all these things: access, quality, safety, clinical leadership, the team experience, the patient experience, culture, and value-based care. Please become familiar with recognizing how to apply health equity lenses to all our work. If you're asked to supply data, help us provide the data and operate in the spirit of education, learning, and a strong mindset.

She concluded, "I've been reading about this a lot lately, and that's looking at social drivers, different needs, and different abilities, not as something that will take too much time to do, but rather something that will provide the capacity for the strength for us to get better together."