Social Determinants of Health: How is Your CMM Practice Screening for Them?

Social Determinants of Health: How is Your CMM Practice Screening for Them?
Ann Nagle, PharmD, MPH, Entira Family Clinics

Background: Social determinants of health (SDoH) are factors from a person’s surroundings that impact health and quality of life. These social determinants that stem from systemic, structural, and environmental factors often impact patient healthcare outcomes. SDoH are categorized into five categories: economic stability, health care access and quality, education access and quality, neighborhood and built environment, and social and community context. Over the past decade, numerous studies have shown that SDoH have a more significant impact on health outcomes than healthcare alone, specifically in chronic conditions such as asthma, diabetes, and cardiovascular health. SDoH impact on health outcomes has been estimated to be as high as 80%.

Comprehensive medication management (CMM) encompasses a whole-person approach which seeks to focus on the patient’s clinical and personal goals of therapy. The comprehensive, holistic service goes beyond optimizing a single medication or focusing on one medical condition. Pharmacists providing CMM assess all conditions and medications to better understand a patient’s motivations and struggles toward health which often includes multiple aspects of SDoH. Therefore, CMM must continue to be promoted as an important pharmacy service which should include SDoH screening.

Evidence: The Pharmaceutical Care Process is part of CMM and starts with identifying a philosophy of practice. This is described by Cipolle, Strand, and Morely as “The philosophy of practice specific to pharmaceutical care describes a purpose for the practice that is to meet the social need to manage drug-related morbidity and mortality, with an explicit objective to care for a patient's drug-related needs by making it the practitioner's responsibility to ensure that all of a patient's drug therapy is appropriate, the most effective available, the safest possible, and is taken as indicated.” This includes a patient-centered and whole-person approach which considers more than just a medication list. In order to identify barriers to health and wellbeing, SDoH screening must be worked into a pharmacist’s patient care process. Since SDoH play such a critical role in patient wellbeing, pharmacists need to push to develop and provide CMM services for their patients. Additionally, those practicing CMM should include screening and identifying SDoH with patients to help drive meaningful interventions, which may not always be in the form of a prescription medication.

How do pharmacists work this screening for SDoH into their practice? The first step is to consider where within a pharmacist’s workflow may be best suited to collect this information. The initial visit with a patient allows for an introduction to CMM services provided by a pharmacist and may be a good place to start. This introduction in which a pharmacist inquires about social and environmental factors creates a relationship with a patient helping them to realize that the care team understands that wellbeing involves more than pharmaceuticals. Some SDoH such as education level or community structure do not change rapidly and follow-up visits may not cover as extensive of a list, so a brief screening evaluating safety, food status, financial status and transportation may be sufficient.

Screening tools for SDoH can be integrated into some electronic health records (EHR) and can be built into a patient care process which includes questions to assess family life, housing, education, employment, health insurance, financial status, safety, legal issues, transportation, and basic needs like food and utilities. To help design these questions or if paper screening tools are preferred, there are resources provided by Association of American Medical College, Kaiser Permanente, National Association of Community Health Centers, American Academy of Family Physicians, Center for Medicare and Medicaid, and Health Leads, all of which may be modified to fit a CMM practice. Once these needs have been identified, pharmacists providing CMM can help navigate healthcare programs and resources on the care team to aid patients in achieving better healthcare outcomes. These needs can be documented and shared amongst the care team using ICD-10 codes and/or integrated health records to form a multi-layered approach to tracking and addressing these barriers.

Discussion & Clinical Impact: Medications cannot work if a patient is not able to take them due to affordability, access to a pharmacy or transportation, or low health literacy to name a few. Similarly, pharmacists providing CMM often recommend lifestyle interventions, such as increasing physical activity, and if patients live in a community where they do not feel safe, this may be a challenge. By knowing the SDoH that impact a patient’s life, pharmacists are able to provide more patient-centered care and can help connect them with resources to improve their health outcomes -- which may be separate from prescribing the medication itself. Therefore it is critical that pharmacists work to provide patient-centered CMM services by including SDOH screening to improve patients’ health.


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