Population Health Must Include Social Determinants: The Approach in the Patient Centered Medical Home


By Dr. Jaan Sidorov

First Posted at Disease Management Care Blog on 5/16/2013

Dr. Jaan Sidorov, host of Disease Management Care Blog
Dr. Jaan Sidorov, host of Disease Management Care Blog

The Disease Management Care Blog’s primary care colleagues are undoubtedly aware of how “social determinants” can undermine the best care planning. So, if you’re going to rely on the Patient Centered Medical Home (PCMH) to increase health care quality and reduce costs, ignoring the impact of poverty or health literacy could lead to poor diabetes control, worsening high blood pressure or more hospital readmissions.

Arvin Garg, Brian Jack and Barry Zuckerman have written a JAMA“Viewpoint” that offers five lessons from pediatric medical homes that can mitigate harmful social determinants:

1) Include social determinants (for example, community factors, substance abuse, education, malnutrition or poverty) in the creation of national treatment guidelines.

2) Develop and implement screening programs to identify any social determinants that could impact medical treatment.

Diabetes control isn’t their top concern

3) Colocate community resources that address social determinant in PCMHs.  Examples include housing programs, job training programs or food pantries.

4) Colocate “outside the box” social programs in PCMHs also.  This is an area ripe for piloting or researching innovative interventions

5) Integrate visiting nurse programs with the PCMH.  Think of the visiting nurses as an extension of the medical home.

As readers of the DMCB are aware, not all PCMH’s can build the full suite of services that make up a medical home. Since health insurers and care management vendors are partnering with primary care physicians to build medical homes, this approach to incorporating social determinants in their programs is worth a closer look.

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Jaan Sidorov MD is the Host of the Disease Management Care Blog where he shares his knowledge and insights about medical home, disease management, population-based health care and managed care. He is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He is primary care by training, managed care by experience and population-based care strategies by disposition. The contents of his blog reflect only his opinions and should not be interpreted to have anything to do with any current or past employers, clients, customers, friends, acquaintances or enemies, personal, professional, foreign or domestic.