‘We are not asking the right questions’: Social health determinants key in rheumatology

AUSTIN, Texas — Asking patients about their socioeconomic barriers to care can help rheumatology providers improve treatment outcomes, according to a presenter at the 2023 Rheumatology Nurses Society annual conference.

“Your social circumstances should not define your treatment success,” Kyra Freeman, MPH, operations manager at Journey Health Services, in California, told attendees. “Health care should be equitable for all.”

Social determinants of health and health disparities are based primarily on education, income level, family support, community safety and job status, according to Freeman. Patients with low education, poor support, uncertain employment, or who live in unsafe communities often experience poorer treatment results.

“These social factors inhibit patients from improving their health,” Freeman said.

It is important to note that social factors determine about half of a patient’s overall health outcomes. In addition, individual patient behaviors like eating habits, exercise, alcohol and tobacco use, and sexual activities can determine another 30% of a patient’s health outcomes, according to Freeman.

“Basically, only 20% of a patient’s health outcomes can be controlled within the health care setting,” she said. “Eighty percent of what happens to our patients is outside of our control.”

Because of this, health care providers should ask patients basic questions about their social factors to better understand the barriers to their care, and more effectively plan treatment programs that meet their specific needs and challenges.

“You can change the way you speak to a patient,” Freeman said. “When we assess the level of social determinants of their care, we can see the disparities.”

Importantly, Freeman noted that about 60% of patients report that providers do not discuss these social factors or disparities in the clinic.

“Vulnerable patients continue to fall through the cracks if are not asking the right questions,” she said. “But that is OK. This is new and it’s challenging. Also, most of us only have 15 to 20 minutes with a patient. We have to learn how to get creative with the small moments we have.”

Patients with rheumatic conditions specifically often experience lower productivity, loss of financial compensation and reduced social interaction due to their conditions. When a patient has detrimental social determinants of health on top of their condition — which is frequently the case — it can compound not only their health outcomes, but also their employment and insurance status, as well as other factors, that can lead to poorer results.

“We need to understand the marginalized patient,” Freeman said. “Impoverished individuals and people of color are more likely to be diagnosed with rheumatic diseases.”

A broader component of the discussion pertains to equity vs. equality, she added. According to Freeman, equality is when everyone is given the same resources. Equity, meanwhile, is providing each patient with what they need to meet their own specific challenges.

“Equality is not always the answer when you have people starting in different places,” Freeman said. “Equity is when you provide people with what they need to be their best selves. Equity is when you base treatment plans on socioeconomic factors as well as their clinical needs.”

Once a patient’s individual needs are ascertained, rheumatology providers should familiarize themselves with the resources available to meet those needs.

For example, medications can now be delivered directly to patients in their homes, which can improve adherence. Interpreter services are also available to help translate for patients who do not speak the same language as their provider. Meanwhile, mobile clinics exist in both urban and rural areas and can help patients who have difficulty with transportation receive mammograms, vaccinations and other basic health services.

However, it can take significant time and energy to locate and connect with all of these resources — time and energy that are in short supply for most rheumatology providers.

“Utilize social workers or community health workers to help patients navigate these systems,” Freeman said. “When there are things we can’t do on our own, we have to reach out to others.”

To that point, health system administrators must collaborate with providers to reach the goals pertaining to health disparities, she added.

“We have to come together to work together continue to be the change agents we set out to be,” Freeman said.