Addressing SDoH from an acute care perspective.

 “Non-compliant:” please, remove this from your lexicon. It’s a pejorative doing injustice to patients and providers alike. 

“Barriers to adherence to a prescribed regimen” is a better descriptor. The behavior has context. Patients very often have obstacles to optimal wellness, some self-inflicted, some constituting a lack of understanding, some from what we now know as the social determinants of health (SDoH).  

We’ve recently learned much about the SDoH: types, sources, and how these manifest in our patients. Accepting the concept of barriers to adherence opens the door to effective interventions to overcome SDoH disadvantages.

For context, I am coming from an acute-care perspective. We have a short time to make an impact, many times only a start. We make the first drive down the fairway, and hopefully, it’s a good set-up for the next shot – primary care, for example. 

Here are two concepts, which if you take away anything else from this article, are essential to addressing SDoH: first, even those on the margins have resources and strengths they can employ toward overcoming barriers. Next, exploiting the patient-specific resources to their maximum potential constitutes a good intervention. As good as can be done is a success.     

A resource and barriers assessment must be part of the written plan of care, preferably built into the documentation template. Here are some examples:

  • In Medicaid expansion states, it is unusual to have uninsured or uninsurable patients, even among the homeless.
  • It’s rare a patient has no income. Be aware, income is an inconsistent indicator of available financial resources. As a well-to-do friend said, “I’m broke, just at a higher level.”
  • Support systems. It may take some effort to cobble together a team, sometimes requiring the engaging of estranged family members. You may have to provide the reality check: this is your mother, child, sibling, etc.
  • Recognition by the patient that help is needed is essential.

Actual barriers and resources are often regional. Many exceptional articles have appeared in RACmonitor and on Monitor Mondays describing the common SDoH barriers. If we ask straightforward questions and listen thoughtfully, our patients will tell us their barriers to optimal wellness. 

The next step is a strategy for taking what the patient has, seeing what else is out there, and putting together in concert with the patient a plan to overcome what can be overcome. Keep it as simple as possible so your patient can follow through. Sometimes a quick intervention solves a big problem. With one 19-year-old homeless patient, I simply asked her to call mom and dad, just to let them know where she was. Family ties took it from there.

Meet your patients where you find them. Don’t ask more of yourself or your patients than to use all the resources that are available to them. The healthcare provider has to step outside their comfort zone in order to facilitate a patient’s acceptance of their role in optimal wellness – which, after all, is where the battle is won. 

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