Renee Kinder

Social determinants of health, understanding what they are, their impact on patient care, and their influence on effective transitions across care settings are all essential for rehab providers.

This area is also gaining an increased appreciation from the Center for Medicare & Medicaid Services, as noted in multiple forms in this year’s proposed rule.

Let’s begin with definitions. 

The World Health Organization defines social determinants of health (SDOH) as being the non-medical factors that influence health outcomes. 

They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.

Furthermore, social determinants of health have an important influence on health inequities which are the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

The following list provides examples of the social determinants of health, which can influence health equity in positive and negative ways:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable health services of decent quality.

Now that we understand the definitions let’s look at what recent publications from our therapy organizations have to say about SDOH.

To begin, an article published by the American Speech Language Hearing Association titled Interprofessional Advocacy for HealthCare Equity notes considerations associated with communication and the role of the speech-language pathologist. 

Specifically stated, communication disabilities add an additional barrier that magnifies medical needs. 

This is significant given that 10% of the U.S. adult population has a communication disability. Related biases significantly affect patient-provider interactions, treatment decisions, treatment adherence and patient health outcomes.

The graphic below shows the impact of poor communication between providers and patients.

The American Occupational Therapy Association has an informative podcast available for viewing titled Social Determinants of Health and OT’s role in novel settings.

This features Joy Doll, OTD, OTR/L, FNAP, leading a deep dive into the importance of Health Information Exchanges, social determinants of health, and the role of OT in primary care and telehealth.

And the American Physical Therapy Association has a recent featured article on “Using Fundamental Interventions To Address Social Determinants of Health.” 

This article tasks PTs to use a socio-ecological model to look beyond intrapersonal factors in evaluating and treating patients and clients.

At the root of all of this guidance, we see a consistent theme with the WHO definition of a person-centered approach. 

A person-centered approach considers the individual as multifaceted, not merely as a “receiver” of services.

This approach demands that providers and individuals share power and responsibility in goal setting, decision making and care management. 

It also requires giving people access to understandable information and decision support tools to equip them and their families with the information to manage their health and wellness, navigate the full span of the health care delivery system, and make their own informed choices about care. 

Finally, let’s review what key areas were present in this year’s SNF proposed rule surround SODH.

A Request for Information was present specifically related to Health Equity Data Considerations. 

In this RFI, CMS stated that it believes that a focused health equity measure would provide specific equity data that will help providers develop innovative and targeted interventions for impacted groups and would additionally provide transparency for beneficiaries. 

They also believe that by leveraging measures to give providers access to disparity information, they would be able to use this data to make informed decisions about their quality improvement initiatives. 

In this RFI, they are requesting feedback from stakeholders on the development and inclusion of health equity quality measures for the SNF QRP.

Additionally, a Request for Comment on a SNF VBP Program Approach to Measuring and Improving Health Equity was included. 

Expressly stated as CMS continues assessing the SNF VBP Program’s policies in light of its operation and its expansion as directed by the Consolidated Appropriations Act, CMS requested public comments on policy changes that they should consider on the topic of health equity. 

CMS specifically requested comments on whether it should consider incorporating adjustments into the SNF value-based purchasing program to reflect the varied patient populations that SNFs serve around the country and tie health equity outcomes to SNF payments under the Program. 

These adjustments could occur at the measure level in forms such as stratification (for example, based on dual status or other metrics) or including measures of social determinants of health. 

These adjustments also could be incorporated at the scoring or incentive payment level in forms such as modified benchmarks, points adjustments or modified incentive payment multipliers (for example, peer comparison groups based on whether the facility includes a high proportion of dual eligible beneficiaries or other metrics). 

CMS requested commenters’ views on which of these adjustments, if any, would be most effective for the SNF VBP Program at accounting for any health equity issues that CMS may observe in the SNF population.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing-Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.