Healthcare professionals are used to treating patients with comorbidities—simultaneous health conditions that can make patients more susceptible to further health problems. But ACA member Michael Ingui, DC, MAS, FIANM (pictured), shares that those comorbidities can be more than what we typically think. “When we think about comorbidities, we often think about hypertension, diabetes, and certainly those conditions can affect someone’s pain, but it’s a lot more than that,” Dr. Ingui explains. “You’re going to have patients that are working two or three jobs, don’t have access to high-quality foods, or may not necessarily be in the best living situation. If there are issues that are affecting them on a societal level, then that’s going to have a tremendous impact on their health.”
“This topic of population health and population health programming extends beyond the four walls of a traditional healthcare system, bringing this strategy to the community and trying to intervene on a community level to identify significant triggers that are affecting a specific subset of population, and then ask, ‘How can we address that to help mitigate some of those affects?’” Dr. Ingui explains.
Social Determinants of Health
One of the main components of this discussion is the concept of social determinants of health, which are nonmedical factors that contribute to a person’s health. There are five major social determinants of health:
- Health and Health Care – access to health care, access to primary care services, health literacy.
- Education – early childhood education and development, enrollment in higher education, high school graduation, language and literacy.
- Economic Stability – employment, food insecurity, housing instability, poverty.
- Neighborhood and Built Environment – access to healthy foods, quality of housing, crime and violence, environmental conditions.
- Social and Community Context – social cohesion/discrimination, incarceration, civic participation.
Dr. Ingui recommends healthypeople.gov as a resource to learn more about social determinants of health.
What Is the Impact?
Dr. Ingui has seen various combinations of these determinant factors impact patients’ health in a myriad of ways. He tells the story of one patient, a 28-year-old single mother who worked as an EMT. She had been having lower back pain for over a year, but physical therapy and two epidurals showed minimal improvement. Using a social determinant of health screening tool, Dr. Ingui discovered that his patient had been displaced from her apartment due to rent costs and had been sleeping on a rubber mat on the floor of her friend’s one-bedroom apartment for more than a year. Because she was prioritizing proper food and clothing for her daughter, she had been unable to eat adequately herself.
Learning this information allowed Dr. Ingui to finally help this patient. He referred the woman to a social worker, as well as local resources that were able to help her get a bed, food and childcare services.
“You don’t know what to look for if you don’t know what to look for,” Dr. Ingui says. “At the heart of it, it comes down to screening. I’ve learned that people are good at hiding these things. Even with an established patient, if I start to notice changes in their behavior or their dress or attitude, I might have them fill out the screening form again.”
Screening Tools
There are several screening tools that ask about social determinants of health from organizations such as the Center for Medicare and Medicaid Services and the National Association of Community Health Centers. Dr. Ingui describes them as similar to health questionnaires to screen for depression and anxiety, and he recommends adding them to intake paperwork.
“Is there any type of economic instability in the house? Is there housing insecurity? Are people worried about being removed from their house? We look at food insecurities, we look at job security,” Dr Ingui explains. “These are topics that, when you go to your general practitioner, no one ever addresses. You probably wouldn’t go to the doctor and say, ‘I’m at risk of losing my job and I’m worried about losing my house.’ When you’re giving a nonintrusive screening questionnaire, the patient is more likely to answer. It can prompt more honest discussion.”
Community Resources
If an initial screen reveals information that needs to be addressed, the next step is to help connect patients with resources in the community. Dr. Ingui recommends looking to county governments, churches or religious organizations and Federally Qualified Health Centers to see what resources are available in your area. He also recommends establishing a relationship with social workers in your community.
“Pretty much every hospital has some kind of social work department,” he explains. “Send an email, introduce yourself. It’s time that we really do truly coordinated care.”
Dr. Ingui works with several social workers to help patients whose social circumstances might be affecting their physical well-being. He will often collaborate with social workers on these cases, setting up weekly calls to check in and update each other about mutual patients. “I may tell the therapist ‘Jane was in last week and she seemed a little more down than usual, I know you’re following up with her on Thursday, I just wanted to let you know that there may be something going on there,’” he says. “The most important thing is continuing on a consistent basis.”
“That true back-and-forth, consistent care, not only is it good medicine—it’s what all of us as physicians should be doing—but more importantly, it’s helping to educate and get educated about both professions and really establish a good professional relationship,” Dr. Ingui explains. “It’s also a great way to get referrals because social workers are seeing patients all the time with low back pain and headaches.”
Talking to Patients
As a healthcare professional, knowing how to access community resources is important, but it’s even more important to connect patients with these resources. Because many of the social determinant issues could be sensitive topics to address with patients, Dr. Ingui recommends putting the patient in the driver’s seat. “You have to make sure patients are receptive,” he says. “It’s already a sensitive topic, so the last thing I want to do is make a big deal of it. Then the patient sees our reaction as not making them feel worse—we’re listening and we’re here to help.”
When he approaches these subjects with patients, he likes to reference their intake form and start by asking them about it to gauge their reaction. “I say, ‘It’s certainly your decision, but I actually know a couple of people, I’ve had a few patients that we’ve helped [with similar circumstances]. If you ever want me to connect you with someone who would be able to address that, let me know and I can happily connect you with that resource.’”
If patients are open to help, Dr. Ingui offers to help them make a contact before they even leave his office. “Engage the patient and then ideally try to connect them with those resources that day,” he suggests. “It takes two minutes, three minutes to make a phone call or send an email and make an introduction. If they can leave my office already having an appointment or a point of contact, they’re more likely to follow up with them.”
Though social health disparities are broad issues and might be daunting, something as simple as implementing a new screening form could lead to real change for patients who are struggling. Dr. Ingui sees the chiropractic profession as a perfect place to raise awareness and take constructive steps.
“As chiropractors, we have a really special model of care where oftentimes we are seeing patients on a regular basis, and often we’re seeing their family and their friends,” Dr. Ingui observes. “We really are kind of the doctor in the community. If I can help educate some of my fellow chiropractors on these strategies, at the very least what to look out for, because were so embedded with the community and we’re oftentimes seeing patients more than their regular medical physician. We can help identify some of these social determinant of health issues and help coordinate care with the various community services that are available and help these patients that otherwise might have gone unnoticed.”
