Understanding social determinants of health

In recent years, the term “social determinants of health” (SDOH) has been used to describe the circumstances that affect health status.

In medicine, we often will identify a treatment to help resolve symptoms of an illness. For example, taking a decongestant will help with the symptoms of a cold. But is simply treating the symptoms enough? Can we identify why a person has caught the cold in the first place and treat those circumstances to prevent the cold to begin with?

SDOH are defined as the conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks [1].

Healthy People 2030 is a plan that establishes goals and objectives to improve health status through implementing health improvement strategies in communities. It relies on understanding SDOH in developing these objectives in order to address the root causes of health issues. Healthy People 2030 relates to SDOH as follows:

• Economic stability considers the 10% of the population that lives in poverty. If people are not able to find and keep a good job that pays a living wage, they may not be able to afford or access healthy food, healthcare services or safe and adequate housing. This can be especially hard on people with disabilities, injuries or chronic conditions, all of which can impact the ability to find steady work, which then causes a downward spiral [2].
• Education access and quality identifies that people with higher levels of education are more likely to be healthier and live longer. However, in low-income families, children with disabilities; children experiencing social discrimination, like bullying; children living in low-income communities with poorly performing schools; and children from low income families are less likely to perform well in school, and less likely to graduate and get a well-paying job. They are more likely to have health issues, such as heart disease, diabetes and depression [3].
• Healthcare access and quality examines the adequacy and quality of healthcare services that people are able to access. Despite the increase in number of insured brought by the Affordable Care Act, about 10% of the population still lacks health insurance and more lack adequate insurance. Lack of oral health coverage, mental health parity, high deductibles and geographic provider shortages all contribute to access issues. The objectives seek to improve access by population demographic categories, healthcare needs, technology and health insurance improvements [4].
• Neighborhood and built environment recognizes that neighborhoods have a major impact on health and wellbeing. Health and safety issues include violence, crime, air and water quality, lead, noise, secondhand smoke and infrastructure. Sidewalks, safe routes to school, bike lanes, access to parks and greenspaces, improved environmental health, transportation and workplace environment all impact health status [5].
• Social and community context connects health with family, friends, coworkers and community. Positive relationships can help improve health status. Where support is lacking, linkage to community support systems and organizations becomes very important [6].

How EMS can improve community health

Each of the social determinants has evidence-based goals and objectives established for communities to use in the development of local health improvement strategies. At the community level, community health needs assessments (CHNAs) are undertaken by the local municipality or county, a health improvement coalition, a local hospital system or other collaboration of healthcare organizations.

At the state level, a State Health Assessment (SHA) and a State Health Improvement Plan (SHIP) provide the overall health status and the goals and objectives for the state. Regional EMS councils and state EMS professional associations can participate in their development and implementation to ensure community EMS assets and resources can be mobilized to address population health improvement.

These assessments provide the basis on which health improvement plans at the community and state level are developed to implement health improvement strategies. Support for communities and states in developing their health assessments and health improvement plans is provided by the National Association of County and City Health Officials. The Public Health Accreditation Board provides the standards for health assessments and health improvement plans in Domain 1 and Domain 5 respectively.

One of the things that community EMS can do to support improved health outcomes is to participate in the CHNA. Community EMS can be a key resource and asset in the strategies adopted to work toward health improvement goals and objectives. A CHNA will provide the community with the information needed to develop a community health improvement plan (CHIP) [7]. This is typically a 3-5-year plan to systematically address public health issues and improve health status. Local and state health departments accredited by the Public Health Accreditation board are required to complete both a health assessment and a health improvement plan [8]. By participating in the CHIP, community EMS can ensure that it is participating in the implementation of health improvement strategies as a community resource.

Community EMS providers can encompass a range of professions. The CHNA may help determine the type of provider training needed in a local community to implement the health improvement strategies. The scope of practice for community EMS is not ALS or BLS, but based on healthcare needs. First responders, EMTs and paramedics should have basic training in the SDOH, public health, chronic disease management, health assessments and disease prevention.

They should also be familiar with community resources and how to make appropriate referrals for services. A good place to start with this is the 211 system. Partnerships with non-EMS providers can enhance services such as nurses, community health workers , oral health technicians, mental health counselors, drug and alcohol counselors, and other professionals [9]. Cross-training EMS providers in these professions can offer more opportunities for EMS organizations to participate in community health improvement programs and provide career advancement opportunities for EMS providers.

Community EMS can contribute to the health status of the population in various ways. Because community EMS makes house calls, they get to see patients in their home environments. This is something that patient care providers in emergency departments and hospitals do not get to do. An example of a community outreach program that addresses the SDOH is the Coordinated Access Referral Education Services (CARES) program in Colorado. This program assists older adults and people with mental health needs in connecting with healthcare and social and community services before the needs become emergencies [10].

Another opportunity for community EMS is in administering assessments using clinical decision tools to assess risk factors. In Ontario and other provinces, paramedics on emergency calls can initiate referrals to community EMS follow-up to assess risk factors such as falls, medication non-compliance, poor hygiene and caregiver burnout. They can also consider adequate housing, income and food security. By using clinically validated assessment tools, with the patient’s permission, a wealth of information can be added to electronic medical records and appropriate referrals can be made [11].

Community EMS is evolving. As the health environment changes, states and communities evaluate their goals and objectives, new regulations are adopted and funding opportunities arise, new and expanded roles for community EMS appear. By participating in local and state health improvement consortiums, EMS can make a positive and important contribution to improving health status.

Next: Treating high-risk pregnancies in the community EMS environment

References

1. Office of Disease Prevention and Health Promotion, “Social Determinants of Health,” U.S. Department of Health and Human Services. Available: https://health.gov/healthypeople/priority-areas/social-determinants-health
2. Office of Disease Prevention and Health Promotion, “Economic Stability.” Available: https://health.gov/healthypeople/objectives-and-data/browse-objectives/economic-stability
3. Office of Disease Prevention and Health Promotion, “Education Access and Quality.” Available: https://health.gov/healthypeople/objectives-and-data/browse-objectives/education-access-and-quality
4. Office of Disease Prevention and Health Promotion, “Health Care Access and Quality.” Available: https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-care-access-and-quality
5. Office of Disease Prevention and Health Promotion, “Neighborhood and Built Environment.” Available: https://health.gov/healthypeople/objectives-and-data/browse-objectives/neighborhood-and-built-environment
6. Office of Disease Prevention and Health Promotion, “Social and Community Context.” Available: https://health.gov/healthypeople/objectives-and-data/browse-objectives/social-and-community-context
7. Center for State, Tribal, Local, and Territorial Support, “Community Health Assessment & Health Improvement Planning,” 13 August 2018. Available: https://www.cdc.gov/publichealthgateway/cha/index.html
8. Center for State, Tribal, Local, and Territorial Support, “Community Health Assessments & Health Improvement Plans,” 24 July 2018. Available: https://www.cdc.gov/publichealthgateway/cha/plan.html
9. Rural Health Information Hub, “Community Paramedicine,” 20 April 2021. Available: https://www.ruralhealthinfo.org/topics/community-paramedicine
10. Johnson RE, Cravens S. “EMS Improves Community Health by Addressing Social Determinants,” EMS World, 19 June 2020
11. Allana A, Pinto AD, “Paramedics Have Untapped Potential to Address Social Determinants of Health in Canada,” Healthcare Policy, vol. 16, no. 3, pp. 67-75, February 2021