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1 Concurrent Session B07 New Approaches to Teaching Social Determinants of Health Community, Diversity, & Equity

2 The Morehouse School of Medicine Adheres to ACCME Essential Areas, Standards, and Policies regarding industry support of continuing medical education. Disclosure of the planning committee and faculty s commercial relationships will be made known at the activity. Speakers are required to openly disclose of any limitations of data and/or any discussion of any off-label, experimental, or investigational uses of drugs or devices in their presentations. Community, Diversity, & Equity

3 Speaker Robert C. Like, MD, MS Community, Diversity, & Equity

4 Rutgers, The State University of New Jersey Mainstreaming Teaching about the Social Determinants of Health in an Academic Medical School Robert C. Like, MD, MS Professor and Director Center for Healthy Families and Cultural Diversity Department of Family Medicine and Community Health Rutgers Robert Wood Johnson Medical School 2018 Center for Healthy Families and Cultural Diversity/Rutgers RWJMS

5 Objectives Share innovative educational activities and clinical interviewing strategies for eliciting and addressing the social determinants of health during patient care encounters Discuss why teamwork, community engagement, and multi-sector partnerships are important for improving community and population health Define the concept of syndemics ( linked or interacting epidemics ), and how employing a syndemic orientation and structural competency can help eliminate multiple health inequities

6 Healthy People 2020 Approach to Social Determinants of Health A place-based organizing framework, reflecting five (5) key areas of social determinants of health (SDOH)

7 LCME: FUNCTIONS STRUCTURE OF A MEDICAL SCHOOL Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree, March 2016 Standard 7.5: Societal Problems Standard 7.6: Cultural Competence/ Health Care Disparities/ Personal Bias Standard 7.9: Interprofessional Collaborative Skills

8 Social Determinants of Health Educational Activities RWJMS Patient Centered Medicine 1 - Full Year Course (required) Multiple Lectures/Small Group Discussions: Disparities and the Isms in Health and Health Care, Culturally and Linguistically Appropriate Service Delivery, Caring for Diverse Populations (e.g., Low Health Literate; Differently Abled; LGBTQ; Veterans; Immigrants/Refugees/Migrants; Religious/Spiritual Communities, Workforce/EOH; Improving Community and Population Health) RWJMS Patient Centered Medicine 2 - Full Year Course (required) (AMA Accelerating Change in Medical Education Grant Program/ Robert Wood Johnson Partners ACO) Home Visits: Improving Chronic Illness Care and Population Health at Home: Maximizing Integrated Care Delivery through Interprofessional Learner Teams - Social Determinants of Health Assessments

9 Social Determinants of Health Educational Activities, continued RWJMS H.I.P.H.O.P. (Homeless & Indigent Population Health Outreach Project) RWJMS DISC Program (Distinction in Service to the Community) Rutgers School of Public Health/RBHS 2018 Bridging the Gaps Summer Program Community-Oriented Interdisciplinary Urban Health Initiative RWJMS Continuing Education Program (3 hrs) Interactive Workshop with Attending Physicians, Fellows, Residents, Clerkship Students, Interprofessional Team Members, and Medical Administrators: Confronting Social Determinants of Health in the Medical Intensive Care Unit for Improving Patient Care

10 Addressing the Social Determinants of Health During Clinical Encounters Eliciting an Expanded Social History The Importance of Creating Safety, Trust, and a Therapeutic Alliance

11 THEESEUS A Mnemonic for Addressing the Social Determinants of Health T: Transportation (e.g., auto, bus, taxi) H: Housing (e.g., home owner, renter, living arrangements, housing stock) E: Eating (e.g., typical diet/nutrition, adequacy of food supplies, meals on wheels, food desert) E: Education (e.g., educational attainment, literacy, numeracy, health literacy) S: Safety (e.g., interpersonal, physical, community, environmental) E: Economics (e.g., current and long-term financial assets, budget for food, clothing, medications) U: Utilities (e.g., electricity, gas, water, heating, phone, internet) S: Social Supports (e.g., family, friends, work, religious, recreational, community Developed by: Robert C. Like, MD, MS Department of Family Medicine and Community Health Rutgers Robert Wood Johnson Medical School 2017

12 Example of MICU Clinical Role Play, Debriefing, and Panel Discussion Patient: You are a 57-yr-old patient with multiple medical problems with 3 rd MICU admission for very high sugars (DKA/Diabetic ketoacidosis) - experiencing medication adherence challenges - dealing with multiple SDOH - pending transfer from MICU to regular floor in hospital Physician: You and the MICU team are taking care of this patient with multiple hospital readmissions for DKA you would like to better understand and address the issues that led to current MICU admission and try to prevent a 4 th readmission make use of THEESEUS clinical interviewing mnemonic to learn more about the SDOH affecting patient s health status, life and functioning, and medication adherence

13 Health Workforce Needs Critical Thinking Systems Thinking/Public Health Approaches Team Skills Community Engagement Collective Action CDC Foundation Health and Wellbeing for All

14 What do you see? What factors are not visible in the picture?

15 Avoiding the Unintended Consequences of Screening for Social Determinants of Health Screening for any condition in isolation without the capacity to ensure referral and linkage to appropriate treatment is ineffective and, arguably, unethical. Garg A. Boynton-Jarrett R, Dworkin P. Avoiding the Unintended Consequences of Screening for Social Determinants of Health. JAMA 2016:316(8):

16 Key Principles for Effectively Incorporating Screening for Social Determinants Into Clinical Practice Ensure Patient and Family-Centered Screening for Social Determinants of Health Integrate Screening with Referral and Linkage to Community-Based Resources Perform Screening Within the Context of a Comprehensive Systems Approach Use a Strength-Based Approach to Support Patients and Their Families Do Not Limit Screening Practices Based on Apparent Social Status Garg A. Boynton-Jarrett R, Dworkin P. Avoiding the Unintended Consequences of Screening for Social Determinants of Health. JAMA 2016:316(8):

17 Accessing Community Resources

18 ICD-10 Z Codes relating to Social Determinants of Health

19 CMS Launches New Model to Test Social Determinants The Innovation Center at the Centers for Medicare and Medicaid Services (CMS) announced the creation of the Accountable Health Communities Model. It is the first-ever CMS innovation model to focus on the social determinants of health.the five-year program will focus on the health-related social needs of Medicare and Medicaid beneficiaries, including building alignment between clinical and community-based services at the local level. This model is expected to raise Medicaid and Medicare beneficiaries' awareness of community-based services, making it more likely they will access community services to receive assistance in times of need or crisis.

20 Syndemics Prevention: An Emerging New Perspective An integrated framework for clinical and public health practice that addresses the biological, socio-cultural, economic, political, and environmental determinants of health through active engagement, empowerment, and collaboration with communities

21 Examples of Syndemics SAVA (Substance Abuse, Violence and AIDS) HIV/AIDS and Other Infectious Diseases (e.g., TB, STIs, Hepatitis, Parasitic) Renocardiac Chaga disease, Rheumatic Heart Disease, and Congestive Heart Failure SARS Chronic Disease Asthma-Influenza Obesity and Diabetes ( Diabesity ) Diabulimia VIDDA (Violence, Immigration, Depression, Diabetes, Abuse) Historical Syndemics Iatrogenic Syndemics Countersyndemics Singer M. Introduction to Syndemics: A Critical Systems Approach to Public and Community Health. San Francisco, CA; John Wiley & Sons, Mendenhall E. Syndemic Suffering: Social Distress, Diabetes, and Depression Among Mexican American Women. Walnut Creek, CA: Left Coast Press, 2012.

22 The Expanded SOAP Framework: Integrating Clinical and Public Health Practice Like RC, Breckenridge MB, Swee DE, Lieberman JA III. Family Health Science and the New Generalist Practitioner. Family Systems Medicine 1993; 11:

23 The Importance of Developing Structural Competency The trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking medication non-compliance, trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health. Metzl J, Hansen H. Structural Competency: Theorizing a New Medical Engagement with Stigma and Inequality. Social Science and Medicine 2014; 103: Structural competency directs clinical training and healthcare systems to intervene at the level of social structures, institutions, and policies that must be altered to improve population health and promote health equity. Hansen H, Metzl J. Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice Journal of Bioethical Inquiry 2016; 13:

24 Meditations We need to comfort the afflicted and afflict the comfortable. Eleanor Roosevelt Pay attention to what makes you angry. That s your issue choosing you. Dr. Lisa Chamberlain, Stanford School of Medicine