Beyond the Social Determinants of Health

Key Takeaways:

• • Social Determinants of Health are widely accepted as key contributors to the majority of health outcomes, but they do not go far enough in tailoring interventions based on the specific circumstances of an individual.
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• • Contextual Care recognizes that individual factors, preferences, and unique situations play a role in health outcomes. The aim is to personalize healthcare delivery to meet the diverse needs of patients.
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• • A combination of both social determinants and context-specific care is essential to achieving cost effective care as well as the best possible care delivery experience and outcome.

What Are Social Determinants of Health:

The social determinants of health (SDOH) are environmental factors that impact an individual’s health. Common wisdom is that these non-clinical SDOH make up the majority of impact on health outcomes. These social determinants include education, employment, income, zip code, access to transportation, safe and secure housing, safe neighborhoods, access to healthful foods, amongst others.

What’s Beyond SDOH? — “Contextual Care”

The recognition and application of Social Determinants of Health to care delivery is a significant advance but still insufficient to achieving optimal patient experience and health equity. Contextual care must become integrated in daily clinical practice if we are to achieve optimal outcomes and experience.

Years of well-documented research make it clear that the impact of non-clinical factors far outweighs the impact of clinical factors on health outcomes. What is not as commonly known is that a significant percentage of these non-clinical factors are still not accounted for by the SDOH listed above, with some experts estimating the gap at as high as 50%.

The Big Question: What Non-clinical Factors Are We Missing That Profoundly Impact Health Outcomes?

I had not heard of contextual factors until I interviewed Yoni Shtein, co-founder and CEO of Laguna Health (Episode #124 of Creating a New Healthcare). That interview was followed by conversations with Dr. Alan Spiro, President and Chief Medical Officer for Laguna health, as well as the research/clinician team of Dr. Saul Weiner and Dr. Alan Schwartz. This duo have spent the past two decades studying this phenomena (Episode #135 of Creating a New Healthcare), and actually coined the terms ‘contextual care’ and ‘contextual barriers’ to care.

Following these interviews, I’ve come to believe contextual care to be a profound advancement, especially in the post-hospital recovery period, where Laguna Health initially focused its attention. I also believe that contextual care can and should be utilized in managing complex chronic conditions, the care of the frail elderly, and other high risk situations like high risk pregnancies and end-stage renal disease. Its benefits  extend not just to clinical outcome, but also to reducing disparities and inequities of care. The benefits of contextualizing care are particularly relevant and urgent as the US is in the midst of a worsening set of crises in caring for the elderly, caring for the disabled, caring for those with complex chronic conditions, and caring for the over 50 million non-professional caregivers.

Contextualizing Care—a divergent, humanistic deployment of healthcare delivery

What Are Contextual Factors?

There are twelve in total. The first six pertain to challenges that patients and their families experience with life circumstances. The last six address behavioral challenges.

These contextual factors include:

1. Access to care
2. Competing responsibilities
3. Social support disruption
4. Financial issues
5. Change in environment
6. Change in resources
7. Skills, abilities and knowledge
8. Emotional state
9. Cultural perspectives and spiritual beliefs
10. Attitude toward illness
11. Attitude toward the provider and the healthcare system
12. Health behaviors  

The Difference Between Contextual Care and SDOH

Think of the relationship between contextual care and SDOH as similar to the relationship between micro and macro economics. Both are necessary and complementary. SDOH deals with “macro” issues such as employment, housing, and education; whereas the contextual factors are “micro” - more immediate, more rapidly changing, and more immediately pliable.

A few major differentiating points between contextual care and the SDOH are as follows:

1. SDOH tend to focus on individuals and families in the lower socio-economic strata, whereas contextual factors are relevant for the vast majority of patients.
2. SDOH are relatively static and the majority of them do not change abruptly. Whereas, contextual factors can change day to day or even hour to hour, requiring more continuous monitoring and immediate response - especially during high risk moments such as after a hospital discharge, a transition of care, or a surgical procedure.
3. Contextual Care touches upon ‘whole person’ health factors that are not typically addressed in SDOH. Issues such as daily emotional state, physical pain, and relational factors like caregiving responsibilities for other family members.
4. SDOH typically require additional resources to address - housing costs and food being two examples of that. Contextual factors, however, can often be addressed rapidly and without significant additional resources or people being mobilized.

Benefits of Contextual Care

One final point here, which may also illustrate the difference between SDOH and contextual factors. Identifying a contextual factor is, in and of itself, part of the engagement and trust building between patient and providers.

The act of asking a patient about contextual factors in real-time:

1. Engages the patient and their family
2. Reduces the dismal sense of isolation and loneliness that often accompanies illness
3. Sheds a light on the hidden fears and struggles patients experience once they’ve left the hospital
4. Contributes to the healing process
5. Builds a trusting relationship and communication channel between provider and patient. This trusting relationship and communication channel is the prerequisite for the development and deployment of a customized care plan.

Successfully Addressing and Deploying Contextual Care

The 4 deployment steps are straightforward.

1. Pick up on the clues that a patient or family is experiencing a contextual barrier to care.
2. Ask “fearless questions” that directly address the contextual issue. These questions may feel uncomfortable, but they are necessary to get at the true reality of the situation that the patient is encountering.
3. Continue probing until you can identify the root cause of the contextual issue.
4. Create a customized and effective plan of care to address that issue.

But, knowing these steps is not enough. We need to develop sophisticated question algorithms and standardized care plans for all of the contextual factors. This step is necessary in order to effectively and efficiently deploy contextual care, and to replicate and deploy contextual care at scale. Another key success factor is to integrate the contextual factors, the question algorithms and the care plan protocols into an automated platform, and to couple it with advanced machine learning technology as well as artificial intelligence software.

This is the work Laguna Health is doing. They’ve incorporated years of research and protocol development into an advanced AI tool, empowering clinicians with a real-time contextual care assistant that’s always listening.

Important Takeaways About Contextual Care

What’s essential to understand is that contextual care factors are not arbitrary. This list was derived from recording, studying and coding over 6,000 provider-patient interactions. Dr. Weiner and Dr. Schwartz have published multiple books and dozens of peer-reviewed studies that outline their rigorous methodologies, the prevalence of these contextual factors in daily clinical practice, and the impact that these factors have on health outcomes. Their research also demonstrates improvements in care and outcomes as a result of deploying contextual care countermeasures.

Unpublished studies conducted by Laguna Health, as well as aggregate customer data, demonstrate that less than 25% of the barriers that patients encounter post-hospital discharge across conditions and procedures are purely clinical. The vast majority of the challenges in post-acute recovery are either contextual or a combination of contextual and clinical. Laguna has recently published outcomes which demonstrate a 50% reduction in billed charges in the first month following discharge from the hospital as a result of deploying their contextual care model. In addition, if readmission is needed, those readmissions resulted in a length of stay 17% lower than a readmission without the Laguna contextual care model. Another publication is forthcoming showing a 35% reduction in 90-day readmissions as a result of Laguna's AI-powered contextual care.

The major point is that we need to go beyond SDOH. If we want to humanize healthcare, we have to include contextual factors as a core part of clinical care delivery.

Dive Deeper on these topics by listening to Dr. Neuwirth's podcast, Creating a New Healthcare...

Reframing the Dialog from Readmissions to Recovery

Dr. Zeev Neuwirth is a healthcare executive, author, and host of the award-winning podcast, ‘Creating a New Healthcare’.

His most recent book, Beyond The Walls - Megatrends, Movements and Market Disruptors Transforming American Healthcare is a testament to the innovative entrepreneurs currently leading the charge to humanize healthcare.

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