Column: Putting social determinants of health to work

This series titled “We Can Heal Healthcare” is content from our partners at Curandi, a not-for-profit membership organization dedicated to reducing health care costs through creating, curating, and facilitating knowledge. We have curated this content because we think it adds value to the work our readers are engaged in. We welcome your feedback on this series.


Social Determinants of Health (SDOH) are conditions that create illness and impair recovery.  They reflect the strength and health of the community and affect those who live there.  A community, like every Complex Adaptive System, can amplify or buffer whatever is good or bad within it.  If we learn to harness SODH amplifiers and buffers in positive ways, we can create a self-reinforcing virtuous cycle where medical care is better and more affordable in a strong, healthy community, and a strong, healthy community can afford better medical care.  Achieving this virtuous circle is possible if we begin seeing healthcare delivery as the living system it is rather than an industrial problem.  

The problem is personal for everyone, and shared by all

Shelly is a 45-year-old single mom with 2 children.  12 months ago, she was diagnosed with Breast Cancer and has been undergoing treatment.  She was a dedicated manager at a large retailer but was terminated when she could not keep up with the demands of her job.  She has lost touch with her friends and feels isolated and depressed.  She tried to pay her bills but eventually lost her home and is trying to find shelter for herself and her children.  Her cancer treatment is ongoing and her condition improving but has become addicted to pain medication.

In the doctor’s office, she tries to appear upbeat, but her growing demands for pain relief creates emotional and unproductive exchanges.  The social and behavioral aspects of care impair her recovery, increase cost, and make it less likely she will return to productive community service.

This problem is bigger than Shelly.  Her cost and suffering will be transformed and amplified in everyone she touches throughout the community.  Her children are at risk.  It will coalesce with other cost and suffering until new and unpredictable circumstances appear from many untold roots.  

Everyone in the community suffers when its fabric that has becomes too worn to support everyone.  This includes healthcare practitioners who are stuck in a system designed with industrial engineering in mind.  

David is Shelly’s primary care physician.  He finished his Internal Medicine residency 15 years ago and is an experienced high-quality practitioner of scientific medicine.  He is very personable and caring which leads him to work and worry more than is healthy.  What bothers David most is his inability do what he spent all those years in school to do, help people get well.

The solution lies in a better model, a 21st century model.  

All around us, we see the power of distributed adaptive networks to lower cost and increase the availability of what we need.  These distributed adaptive networks are Complex Adaptive Solutions capable of taming Complex Adaptive Problems.   Applying this to healthcare is possible with an enabling, innovative technology that maps purpose and context in measurable outcomes.   This creates a new marketplace that can self-organize to serve every point of care.  We can imagine how that might improve Shelly’s situation.

What Dr. David needs is an uncomplicated way to find and support new options.  He needs a straightforward way to connect the best services to his medical care based on their track record and cost – these connections are the basis of an adaptive network.   This network would track Shelly’s status and goals with “in-flight instrumentation” so Dr. David can adapt quickly when needed.  With these tools, Dr. David could be judged and paid more on his ability to help Shelly and less on his adherence to organizational process.   

This vision is only one possibility that can grow from the same principles.  Community social and behavioral health offers a harvest of opportunities.

We grow a new model where it will have the most impact, integrating SDOH.  

Community social services is a natural place to begin setting up a collaborative and interconnected system around an integrating hub.  This non-medical hub would coordinate an infrastructure sharing risk for medical outcome measures.  Its job would be to develop more resources in the community and to integrate those independent resources into a distributed and adaptive network; one that delivers measurable results in specific individuals found with high-risk medical conditions complicated by social determinants.

Such an integrated network would create change using three layers of service, accessible by any point of care, through the community social network service.

  1. Access to Healthcare: This is plan enrollment and not new by itself.  What is new is the active engagement of social service agencies who are already working in the neighborhoods.  They have different access and methods to complement existing efforts.
  2. Rapid Response: This is a new service that shares responsibility for specific high-risk/high-need members.  It is outcome oriented which enables new payment methodologies and identification of what really works in real-world situations.  Knowing what works supports better funding leading to better outcomes.  Measurable improvement will be visible in the first year.
  3. Long term community improvement: The natural result of systems that improve community from the perspective of the whole is sustainable improvement.   Current retrospective analysis of state level funding shows we should see improvement in 3 to 4 years.

This is a limited snapshot of a bigger story.  Learn more at the from the Connecting Savings to the Social Determinants of Health panel at the Oregon State of Reform 2017 conference.