Asking the Question: The First Step in Understanding Social Determinants of Health

In this age of accountable health care, the true meaning of the word “accountable” is taking on greater importance with social determinants of health.  In fact, a patient’s life beyond the exam room may be the determining factor in the success of care started in the exam room. A recently- published study by the Permanente Medical Group uncovered the fact that one-third of Americans are struggling to provide the basic needs of stable housing, adequate food, and reliable transportation. Just having some measure of social determinants available in an analytical system is helpful, but it does not appear to be sufficient to achieve the desired result of a better clinical outcome.  Simply asking the question about a patient’s social condition can be a powerful beginning toward improving health. Physicians must not only ask, “What is clinically wrong today?” but also, “How is life going?” In the sales world this is the “What do you need, and how can I get it to you” question.

Physicians taking on financial risk in ACOs amplifies the importance of asking and getting answers to these vital questions. The best place to close the gaps in care specifically related to social determinants is at the physician’s office. The thick bureaucracy of the managed care organization is too far away from the patient to be an effective place to discover this data. The hospital is an episodic resource. Furthermore, the intimate and personal nature of the question is best asked in the office-based exam room. Once the question is asked there are four elements that can help close the gaps in care influenced by the social environment.[ii]  

1.  Identifying the patient’s need is a good start.  This could be something as simple as big print instructions.  Alternatively the question could raise a more complex solution like a working refrigerator for a diabetic patient.  Any of these could be the answer to the “How is it going” question.

2.  Finding the right resources to meet those social needs is a key part of the solution. No one is asking the physician’s office to supply every need for these socially-complex patients. Nonetheless, physicians and their team are in a central position to manage the available resources in the community. While it is true that the physician is not a social worker, these are social solutions to medical problems.  Answering the question raised by these problems leads to better medical outcomes.  Our changing health system has uncovered the importance of health care as a team effort. Managing social determinants requires that this team make the effort to connect the patient with the resources that will help solve their particular problem.

3.  We all know that follow-up is part of care delivery. The care team will know that follow up of a working refrigerator in keeping the insulin fresh is as important as measuring daily weights in a congestive heart failure patient. While it is important that patients act responsibly, sometimes patients simply do not have the resources to be responsible.

4.  Social determinants are not just “things” that we get for patients. It is not just getting access to nutritious food but also teaching the socially-marginal patient how to use the food. In 2016, Geisinger launched their “Fresh Food Pharmacy” providing fresh nutritious food and education to their needy diabetic patients. Over the next 18 months they saw the overall costs for that population drop 80 percent. In this situation “food becomes medicine.” We all have social determinants of one degree or another; however, we all do not need intensive social care to achieve our clinical objectives. The question is simple: “What do you need to stay well and how can we get it to you?”


[ii] ibid

Craigan Gray

About the Author


Craigan Gray, MD, MBA, JD

Dr. Craigan Gray, Salient Healthcare’s Chief Medical Officer, brings rich experience from private practice, hospital leadership, and governmental health-benefit programs. Prior to joining Salient, Dr. Gray was director of North Carolina’s $12 billion Medicaid program. His time as VPMA at Bon Secours Our Lady of Bellefonte Hospital in Kentucky was distinguished by moving the facility into the top-quality performance tier for Health Grades and CMS health quality indicators. Dr. Gray is a Stanford University trained Obstetrician/Gynecologist. In addition to an MD degree, Dr. Gray holds an MBA degree and a JD degree. He is a Certified Physician Executive and is published in various medical journals.

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