In recent blogs, we have discussed the importance of social determinants of health (SDoH) and the value of the biopsychosocial model of medicine. Today we will explore the challenges of implementing effective interventions for SDoH. This is clearly an area of intense interest as a quick search on the internet revealed over 3.2 million results for “integration of social services with health care.”
Indeed, there are many promising initiatives being implemented. In Boston, a housing intervention program for “medically complex” families with unstable housing demonstrated improved health for children and improved mental health for parents in the six months post-intervention in a small randomized controlled trial (RCT).1 The Veterans Administration, after incorporating social workers into primary care practices observed among high risk patients, a 4.4% decrease in the number of veterans with hospital admissions and a 3% decrease in those with emergency department visits.2 Area Agencies on Aging have long been partnering with health care organizations to address social needs, and survey data collected from 2008-2013 showed a $136 reduction in average annual Medicare spending per beneficiary for those counties where agencies for the aging partnered with a hospital.3
Unfortunately, most of these promising stories are based on observational data or very small, unreplicated randomized trials. Larger, well designed studies are sparse and often fail to demonstrate benefit. One such trial was done by the Camden Coalition in New Jersey. They randomized 800 “high utilizer” hospitalized patients with complex medical and social challenges, and the intervention group received several months of visits post-discharge by a team of nurses, social workers, and community health workers to coordinate outpatient care and link them with social services. While there was a 38% drop in admissions in the six months post-intervention compared to the six months prior, there was no difference between the intervention and control group.4 This particular result demonstrates the critical importance of RCTs versus a dependence on observational studies alone.
Another large RCT in Baltimore employed a “multicomponent intervention including an online tool to help refer clients to community resources, meet-and-greet sessions between community-based organization staff and healthcare staff, and research assistants.” This study demonstrated no significant change in health care utilization.5
While it is easy to get discouraged looking at the results of these studies, modern medicine has demonstrated success only when we look honestly and carefully at the science behind our work, and most importantly, we diligently adhere to the scientific method. There are many promising hypotheses being tested in the domain of social services and particularly in how to best integrate them with healthcare. As healthcare providers are increasingly capturing SDoH information from their patients, careful attention to evidence on evolving models of intervention will be important. Healthcare, social services, and the communities they serve will all benefit if there is effective collaboration across these sectors.
1https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01569
2https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01589
3https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01515
4https://www.nejm.org/doi/full/10.1056/NEJMsa1906848
5https://www.sciencedirect.com/science/article/abs/pii/S0749379719301631
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